Prostaglandin and vasoconstrictor pharmaceutical  compositions and methods of use

ABSTRACT

Compositions containing a prostaglandin agent and a vasoconstrictor agent for ophthalmic applications are provided as well as methods of treating ophthalmic diseases using the same. In certain embodiments, the compositions and methods are useful for treating glaucoma without causing conjunctival hyperemia.

CROSS REFERENCE TO RELATED APPLICATIONS

This application claims the benefit of U.S. Provisional Patent Application Ser. No. 61/637,597, filed Apr. 24, 2012, the disclosure of which is hereby incorporated in its entirety herein by reference.

BACKGROUND OF THE INVENTION

Based on its etiology, glaucoma can be classified into primary and secondary glaucoma. Primary glaucoma, also known as congenital glaucoma, can occur in the absence of other ocular conditions and its underlying causes are not known. However, it is known that increased intraocular pressure (IOP) observed in primary glaucoma is due to the obstruction of aqueous humor flow out of the eye. Secondary glaucoma results from another pre-existing ocular disease such as, uveitis, an intraocular tumor, enlarged cataract, central retinal vein occlusion, trauma to the eye, operative procedures and intraocular hemorrhage. Generally, any interference with the outward flow of aqueous humor from the posterior chamber into the anterior chamber and subsequently, into the canal of Schlemm can lead to secondary glaucoma.

Considering all types of glaucoma together, this ocular disorder occurs in about 2% of all persons over the age of 40. Unfortunately, glaucoma can be asymptomatic for years before progressing to a rapid loss of vision. In cases where surgery is not indicated, topical β-adrenoreceptor antagonists (or β-blockers) have traditionally been the drugs of choice for treating glaucoma. Further, certain prostaglandins and their analogues have been recommended for use in glaucoma management. For example, the prostaglandin analogue bimatoprost (Lumigan®) given at a dose of 0.03%, once daily, is a highly efficacious intraocular pressure (IOP) lowering drug. It has a very high systemic safety margin in studies conducted in laboratory animals. However, bimatoprost as well as many other topical anti-glaucoma medications produce conjunctival hyperemia as a side effect. Conjunctival hyperemia (or “red eye”) refers to vasodilatation of the conjunctival blood vessels. The vasodilatation of the conjunctival blood vessels results in increased blood supply to the vessels or even rupture of the vessels, which causes redness of the eye, reduced visual acuity, severe ocular pain, and photophobia (light sensitivity).

The present invention solves these as well as other problems in the art by, inter alia, providing compositions of sub-therapeutic concentrations of a vasoconstrictor agent (e.g., a beta adrenergic antagonist) in combination with a pharmaceutically effective amount of a prostaglandin agent (e.g., is defined to include prostaglandins, prostaglandin analogs, prostaglandin derivatives or prostamides such as bimatoprost) and methods of using such compositions to treat ophthalmic diseases without causing conjunctival hyperemia.

BRIEF SUMMARY OF THE INVENTION

Presented herein are, inter alia, compositions containing a prostaglandin agent and a vasoconstrictor agent (e.g. at sub-therapeutic concentrations) for ophthalmic applications as well as methods of treating ophthalmic diseases. In certain embodiments, the compositions and methods are useful for treating the symptoms of glaucoma. The compositions and methods provided herein are particularly useful for treating increased intraocular pressure (IOP) without causing the adverse effect of conjunctival hyperemia.

In one aspect, a composition including a prostaglandin agent and a vasoconstrictor agent is provided. In another aspect, a method of reducing increased intraocular pressure (IOP) in a subject in need thereof is provided. The method includes administering to the subject a therapeutically effective amount of an ophthalmic pharmaceutical formulation including a prostaglandin agent and a vasoconstrictor agent.

Some embodiments of the invention include:

1. A composition comprising a prostaglandin agent and a vasoconstrictor agent. 2. The composition of paragraph 1, wherein said composition is an ophthalmic pharmaceutical formulation further comprising an ophthalmically acceptable excipient. 3. The composition of paragraph 1, wherein said prostaglandin agent is present in a therapeutically effective amount. 4. The composition of paragraph 1, wherein said vasoconstrictor agent is present in a sub-therapeutic amount. 5. The composition of paragraph 2, wherein said prostaglandin agent and said vasoconstrictor agent are present in a combined amount effective to treat an ophthalmic disease. 6. The composition of paragraph 2, wherein said ophthalmic pharmaceutical formulation is a gel formulation. 7. The composition of paragraph 2, wherein said ophthalmic pharmaceutical formulation is an aqueous solution. 8. The composition of paragraph 2, wherein said prostaglandin agent is bimatoprost. 9. The composition of paragraph 8, wherein said bimatoprost is present in an amount approximately equal to or less than about 0.1% w/w. 10. The composition of paragraph 8, wherein said bimatoprost is present in an amount of about 0.03% w/w. 11. The composition of paragraph 2, wherein said prostaglandin agent is travoprost. 12. The composition of paragraph 11, wherein said travoprost is present in an amount approximately equal to or less than about 0.1% w/w. 13. The composition of paragraph 11, wherein said travoprost is present in an amount of about 0.004% w/w. 14. The composition of paragraph 2, wherein said prostaglandin agent is latanoprost. 15. The composition of paragraph 14, wherein said latanoprost is present in an amount approximately equal to or less than about 0.1% w/w. 16. The composition of paragraph 14, wherein said latanoprost is present in an amount of about 0.005% w/w. 17. The composition of paragraph 2, wherein said vasoconstrictor agent is an alpha adrenergic agonist. 18. The composition of paragraph 2, wherein said vasoconstrictor agent is a beta adrenergic antagonist. 19. The composition of paragraph 18, wherein said beta adrenergic antagonist is timolol. 20. The composition of paragraph 19, wherein said timolol is present in a sub-therapeutic amount. 21. The composition of paragraphs 18 or 20, wherein said sub-therapeutic amount is an amount less than about 0.25% w/w or less than 0.1% w/w or less than 0.05% w/w or in a range from 0.0001%-0.001% w/w. 22. The composition of paragraph 19, wherein said timolol is timolol maleate. 23. The composition of paragraph 19, wherein said timolol is timolol hemihydrate. 24. The composition of paragraph 18, wherein said beta adrenergic antagonist is betaxolol. 25. The composition of paragraph 24, wherein said betaxolol is present in a sub-therapeutic amount. 26. The composition of paragraph 25, wherein said sub-therapeutic amount is an amount less than about 0.05% w/w or in an amount less than 0.005% w/w. 27. The composition of paragraph 24, wherein said betaxolol is a betaxolol salt. 28. The composition of paragraph 18, wherein said beta adrenergic antagonist is levobunolol. 29. The composition of paragraph 28, wherein said levobunolol is present in a sub-therapeutic amount. 30. The composition of paragraph 29, wherein said sub-therapeutic amount is an amount less than about 0.25% w/w or less than 0.025% w/w. 31. The composition of paragraph 28, wherein said levobunolol is a levobunolol salt. 32. The composition of paragraph 18, wherein said beta adrenergic antagonist is metipranolol. 33. The composition of paragraph 32, wherein said metipranolol is present in a sub-therapeutic amount. 34. The composition of paragraph 33, wherein said sub-therapeutic amount is an amount less than about 0.3% w/w or 0.03% w/w. 35. The composition of paragraph 32, wherein said metipranolol is a metipranolol salt. 36. The composition of paragraph 2, further comprising a buffering agent, a tonicity agent, a salt, and a preservative. 37. The composition of paragraph 2, consisting essentially of bimatoprost, timolol, a buffering agent, a tonicity agent, a salt, a thickening agent and a preservative. 38. The composition of paragraph 37, wherein said timolol is present in a sub-therapeutic amount. 39. The composition of paragraph 38, wherein said sub-therapeutic amount is an amount less than about 0.25% w/w or less than 0.05% w/w or 0.005% w/w. 40. The composition of paragraph 2, consisting essentially of bimatoprost, betaxolol, a buffering agent, a tonicity agent, a salt, a thickening agent and a preservative. 41. The composition of paragraph 40, wherein said betaxolol is present in a sub-therapeutic amount. 42. The composition of paragraph 41, wherein said sub-therapeutic amount is an amount less than about 0.25% w/w. 43. The composition of paragraph 2, consisting essentially of bimatoprost, levobunolol, a buffering agent, a tonicity agent, a salt, a thickening agent and a preservative. 44. The composition of paragraph 43, wherein said levobunolol is present in a sub-therapeutic amount. 45. The composition of paragraph 44, wherein said sub-therapeutic amount is an amount less than about 0.25% w/w. 46. The composition of paragraph 2, consisting essentially of bimatoprost, metipranolol, a buffering agent, a tonicity agent, a salt, a thickening agent and a preservative. 47. The composition of paragraph 46, wherein said metipranolol is present in a sub-therapeutic amount. 48. The composition of paragraph 47, wherein said sub-therapeutic amount is an amount less than about 0.3% w/w. 49. A method of reducing intraocular pressure (IOP) in a subject in need thereof, said method comprising: administering to said subject a therapeutically effective amount of an ophthalmic pharmaceutical formulation comprising a prostaglandin agent and a vasoconstrictor agent. 50. The method of paragraph 49, wherein said prostaglandin agent is present in a therapeutically effective amount and said vasoconstrictor agent is present in a sub-therapeutic amount. 51. The method of paragraph 49, wherein said prostaglandin agent is bimatoprost and wherein said vasoconstrictor agent is timolol. 52. The method of paragraph, wherein timolol is present in an amount less than about 0.25% w/w. 53. The method of paragraph 49, wherein said ophthalmic pharmaceutical formulation further comprises a buffering agent, a tonicity agent, a salt, a thickening agent and a preservative. 54. The method of paragraph 49, wherein said ophthalmic pharmaceutical formulation consists essentially of bimatoprost, timolol, a buffering agent, a tonicity agent, a salt, a thickening agent and a preservative. 55. The method of paragraph 54, wherein bimatoprost is present in a therapeutically effective amount and the timolol is present in a sub-therapeutic amount. 56. The composition of paragraph 4, wherein the vasoconstrictor is selected from the group consisting of befunolol, betaxolol, carteolol, levobunolol, metipranolol, timolol, brimonidine, tetrahydrozolone hydrochloride and mepindolol. 57. The composition of paragraph 56, where the vasoconstrictor is present in an amount selected from the group consisting of 0.01 to about 0.06, from about 0.02 to about 0.06, from about 0.03 to about 0.06, from about 0.04 to about 0.06, from about 0.05 to about 0.06, from about 0.001 to about 0.04, from about 0.002 to about 0.04, from about 0.003 to about 0.04, from about 0.004 to about 0.04, from about 0.005 to about 0.04, from about 0.006 to about 0.04, from about 0.007 to about 0.04, from about 0.008 to about 0.04, from about 0.009 to about 0.04, from about 0.01 to about 0.04, from about 0.02 to about 0.04, from about 0.03 to about 0.04, from about 0.001 to about 0.02, from about 0.002 to about 0.02, from about 0.003 to about 0.02, from about 0.004 to about 0.02, from about 0.005 to about 0.02, from about 0.006 to about 0.02, from about 0.007 to about 0.02, from about 0.008 to about 0.02, from about 0.009 to about 0.02, from about 0.01 to about 0.02, from about 0.001 to about 0.01, from about 0.002 to about 0.01, from about 0.003 to about 0.01, from about 0.004 to about 0.01, from about 0.005 to about 0.01, from about 0.006 to about 0.01, from about 0.007 to about 0.01, from about 0.008 to about 0.01, or from about 0.009 to about 0.01% (w/w).

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1. Conjunctival hyperemia scale scores at each study visit in patients treated with topically applied bimatoprost 0.03% once daily. Results are expressed as the mean hyperemia score of three vessel-bed scores from 33-39 patients with bilateral open-angle glaucoma or ocular hypertension. Adapted from Abelson M B et al., Adv. Ther. 2003; 20:1-13.

FIG. 2. (Top) Photomicrographs of conjunctival specimens stained with hematoxylin and eosin (H&E, ×200), showing vascular congestion (arrows). (Top left) Specimen from patient 3 of the control group. (Top right) Specimen from patient 4 of the bimatoprost group. (Bottom) Photomicrographs of conjunctival specimens stained with H&E (×400) showing features of acute inflammatory response. (Bottom left) Specimen from patient 1 of the control group, showing vascular congestion with polymorphonuclear leukocyte margination (long arrow), diapedesis phenomenon (short arrow), and inflammatory cell infiltrate. (Bottom right) Specimen from patient 8 of the bimatoprost group, showing vascular congestion with polymorphonuclear leukocyte margination (arrow). Reprinted from FIG. 1 of Leal B C et al, Am J Ophthalmol 2004; 138:310-313, with permission from Elsevier.

FIG. 3. Concentration-response curves for (FIG. 3A) bimatoprost and (FIG. 3B) latanoprost free acid in histamine-precontracted endothelium-intact and endothelium-denuded rabbit isolated jugular veins. Results are expressed as mean±S.E.M. of 5-6 animals. FIG. 3A adapted from Chen J et al., Invest Ophthalmol Vis Sci 2004; 45:ARVO E-Abstract 2609; FIG. 3B extends results reported in Chen J et al., Invest Ophthalmol Vis Sci 2004; 45:ARVO E-Abstract 2609; and Pharmacology Review of New Drug Application 21-275. FDA/Center for Drug Evaluation and Research. 2001; Part 1 and Part 2:1-107. Available online at http://www.fda.gov/cder/foi/nda2001/21275_Lumigan.htm.

FIG. 4. Concentration-response curves for (FIG. 4A) bimatoprost and (FIG. 4B) latanoprost free acid in the presence or absence of indomethacin in endothelium-intact rabbit isolated jugular veins. Results are expressed as mean±S.E.M. of 7 animals and extend previous results reported in Pharmacology Review of New Drug Application 21-275. FDA/Center for Drug Evaluation and Research. 2001; Part 1 and Part 2:1-107. Available online at http://www.fda.gov/cder/foi/nda/2001/21275_Lumigan.htm.

FIG. 5. Concentration-response curves for (FIG. 5A) bimatoprost and (FIG. 5B) latanoprost free acid in the presence of 100 μM L-NAME or 100 (μM D-NAME control in endothelium-intact rabbit isolated jugular veins. Results are expressed as mean±S.E.M. of 6 animals. *P≦0.05, compared to responses in D-NAME pretreated tissues at the same concentration, paired t-test.

FIG. 6. Effects of L-NAME (test eye) and D-NAME control (contralateral fellow eye) on ocular surface hyperemia elicited by (FIG. 6A) 0.1% bimatoprost, (FIG. 6B) 0.005% latanoprost, or (FIG. 6C) 0.01% PGE₂, topically applied to both eyes of each dog at time 0. Values are expressed as mean±S.E.M. of 8 animals. *P≦0.05, difference from baseline (time 0), Wilcoxon signed-rank test for paired observations. Data from Chen J et al., Invest Ophthalmol Vis Sci 2004; 45:ARVO E-Abstract 2609.

DETAILED DESCRIPTION OF THE INVENTION

The terms “a,” “an,” or “the” as used herein not only include aspects with one member, but also aspects with more than one member. For example, an embodiment including “a buffer and a chelating agent” should be understood to present aspects with at least a second buffer, at least a second chelating agent, or both.

The term “or” as used herein should in general be construed non-exclusively. For example, an embodiment of “a formulation including A or B” would typically present an aspect with a formulation including both A and B. “Or” should, however, be construed to exclude those aspects presented that cannot be combined without contradiction (e.g., a formulation pH that is between 9 and 10 or between 7 and 8).

“Agent” as used herein indicates a compound or mixture of compounds that, when added to a pharmaceutical formulation, tend to produce a particular effect on the formulation's properties. For example, a formulation including a thickening agent is likely to be more viscous than an otherwise identical comparative formulation that lacks the thickening agent.

“Formulation,” “composition,” and “preparation” as used herein are equivalent terms referring to a composition of matter suitable for pharmaceutical use (i.e., producing a therapeutic effect as well as possessing acceptable pharmacokinetic and toxicological properties).

As used herein, the term “pharmaceutically” acceptable is used as equivalent to physiologically acceptable. In certain embodiments, a pharmaceutically acceptable composition or preparation will include agents for buffering and preservation in storage, and can include buffers and carriers for appropriate delivery, depending on the route of administration.

As used herein, the terms “prevent” and “treat” are not intended to be absolute terms. Treatment can refer to any delay in onset, e.g., reduction in the frequency or severity of symptoms, amelioration of symptoms, improvement in patient comfort, and the like. The effect of treatment can be compared to an individual or pool of individuals not receiving a given treatment, or to the same patient before, or after cessation of, treatment.

The terms “subject,” “patient,” “individual,” and the like as used herein are not intended to be limiting and can be generally interchanged. That is, an individual described as a “patient” does not necessarily have a given disease, but may be merely seeking medical advice.

The term “subject” as used herein includes all members of the animal kingdom prone to suffering from the indicated disorder. In some aspects, the subject is a mammal, and in some aspects, the subject is a human.

The terms “effective amount,” “therapeutically effective amount” or “pharmaceutically effective amount” as used herein refer to that amount of the therapeutic agent sufficient to ameliorate one or more aspects of the disorder. The result can be reduction and/or alleviation of the signs, symptoms, or causes of a disease, or any other desired alteration of a biological system. For example, an “effective amount” for therapeutic uses is the amount of the composition comprising an agent as set forth herein required to provide a clinically significant decrease in an ophthalmic disease. For example, for the given aspect (e.g., length of incidence), a therapeutically effective amount will show an increase or decrease of at least 5%, 10%, 15%, 20%, 25%, 40%, 50%, 60%, 75%, 80%, 90%, or at least 100%. Therapeutic efficacy can also be expressed as “-fold” increase or decrease. For example, a therapeutically effective amount can have at least a 1.2-fold, 1.5-fold, 2-fold, 5-fold, or more effect over a control. An appropriate “effective” amount in any individual case may be determined using techniques, such as a dose escalation study.

The term “sub-therapeutic amount” or “sub-therapeutic concentration” as provided herein refers to an amount of a therapeutic agent (e.g. drug) that is insufficient to provide a therapeutic effect in the absence of an additional active agent. In some embodiments, the sub-therapeutic amount is less than the clinically approved amount or concentration of that therapeutic agent. In some embodiments, a sub-therapeutic amount is less than the lowest clinically approved amount of a therapeutic agent. A clinically approved amount of a therapeutic agent is the amount approved by the U.S. Food and Drug Administration (FDA) or an equivalent regulatory entity, to be safe and effective when used as directed.

“Treating” or “treatment” as used herein (and as well-understood in the art) also broadly includes any approach for obtaining beneficial or desired results in a subject's condition, including clinical results. Beneficial or desired clinical results can include, but are not limited to, alleviation or amelioration of one or more symptoms or conditions, diminishment of the extent of a disease, stabilizing (i.e., not worsening) the state of disease, prevention of a disease's transmission or spread, delay or slowing of disease progression, amelioration or palliation of the disease state, diminishment of the reoccurrence of disease, and remission, whether partial or total and whether detectable or undetectable. In other words, “treatment” as used herein includes any cure, amelioration, or prevention of a disease. Treatment may prevent the disease from occurring; inhibit the disease's spread; relieve the disease's symptoms (e.g., ocular pain, seeing halos around lights, red eye, very high intraocular pressure), fully or partially remove the disease's underlying cause, shorten a disease's duration, or do a combination of these things.

“Treating” and “treatment” as used herein include prophylactic treatment. Treatment methods include administering to a subject a therapeutically effective amount of an active agent.

The administering step may consist of a single administration or may include a series of administrations. The length of the treatment period depends on a variety of factors, such as the severity of the condition, the age of the patient, the concentration of active agent, the activity of the compositions used in the treatment, or a combination thereof. It will also be appreciated that the effective dosage of an agent used for the treatment or prophylaxis may increase or decrease over the course of a particular treatment or prophylaxis regime. Changes in dosage may result and become apparent by standard diagnostic assays known in the art. In some instances, chronic administration may be required. For example, the compositions are administered to the subject in an amount and for a duration sufficient to treat the patient.

The term “disease” refers to any deviation from the normal health of a mammal and includes a state when disease symptoms are present, as well as conditions in which a deviation (e.g., infection, gene mutation, genetic defect, etc.) has occurred, but symptoms are not yet manifested. According to the present invention, the methods disclosed herein are suitable for use in a patient that is a member of the Vertebrate class, Mammalia, including, without limitation, primates, livestock and domestic pets (e.g., a companion animal). Typically, a patient will be a human patient.

As used herein, “topical application,” “topical administration,” and “topically administering” are used interchangeably herein and include the administration of a composition to the eye, the mucosal or dermal area proximal to the eye. Topical application or administering may result in the delivery of an active agent to the eye or skin, a localized region of the body, a localized volume of the body, or the systemic circulation.

“Topical formulation” and “topical pharmaceutical composition” are used interchangeably herein and include a formulation that is suitable for topical application to the eye or dermal area proximal to the eye, or other localized region of the body. A topical formulation may, for example, be used to confer a therapeutic benefit to its user. Specific topical formulations can be used for topical, local, regional, or transdermal application of substances.

As used herein, the terms “application,” “apply,” and “applying” used in reference to a topical composition product or method of using a composition or a product, refer to any manner of administering a topical composition or a product to the eye, the mucosal or dermal area proximal to the eye of a patient which, in medical or cosmetology practice, delivers the composition or the product to patient's eye, the mucosal or dermal area proximal to the eye. Smearing, rubbing, spreading, spraying a topical composition, with or without the aid of suitable devices, on a patient's skin are all included within the scope of the term “application,” as used herein. The term “topical” or “topically” in reference to administration or application of a composition or a product refers to epicutaneous administration or application, or administration onto skin. The term “topically active agent” as used herein refers to a compound that is effective in a treatment of a skin condition when administered topically. It is to be understood that a topically active agent can have a local or a systemic effect, or both, when administered topically. The term “topical,” when used in reference to a composition or a product refers to a composition or a product formulated for topical application.

The terms “adverse effect” or “side effects” as used herein refer to a harmful and undesired effect associated with the use of a medication (i.e. drug). An adverse effect may be termed a side effect, when judged to be secondary to a main or therapeutic effect. Adverse effects or side effects may occur when starting treatment, increasing treatment dosage or discontinuing treatment with a drug. Adverse effects may also be caused by drug interaction when more than one drug is administered. In some embodiments, the side effect of administering therapeutically effective amounts

The abbreviations used herein have their conventional meaning within the chemical, biological or pharmaceutical arts.

The terms “about” and “approximately equal” are used herein to modify a numerical value and indicate a defined range around that value. If “X” were the value, “about X” or “approximately equal to X” would generally indicate a value from 0.90X to 1.10X. Any reference to “about X” minimally indicates at least the values X, 0.90X, 0.91X, 0.92X, 0.93X, 0.94X, 0.95X, 0.96X, 0.97X, 0.98X, 0.99X, 1.01X, 1.02X, 1.03X, 1.04X, 1.05X, 1.06X, 1.07X, 1.08X, 1.09X, and 1.10X. Thus, “about X” is intended to disclose, e.g., “0.98X.” When “about” is applied to the beginning of a numerical range, it applies to both ends of the range. Thus, “from about 6 to 8.5” is equivalent to “from about 6 to about 8.5.” When “about” is applied to the first value of a set of values, it applies to all values in that set. Thus, “about 7, 9, or 11%” is equivalent to “about 7%, about 9%, or about 11%.”

As used herein, the phrase “pharmaceutically acceptable salts” refers to salts of the active compound(s) which possess the same pharmacological activity as the active compound(s) and which are neither biologically nor otherwise undesirable. A salt can be formed with, for example, organic or inorganic acids. Non-limiting examples of suitable acids include acetic acid, acetylsalicylic acid, adipic acid, alginic acid, ascorbic acid, aspartic acid, benzoic acid, benzenesulfonic acid, bisulfic acid, boric acid, butyric acid, camphoric acid, camphorsulfonic acid, carbonic acid, citric acid, cyclopentanepropionic acid, digluconic acid, dodecylsulfic acid, ethanesulfonic acid, formic acid, fumaric acid, glyceric acid, glycerophosphoric acid, glycine, glucoheptanoic acid, gluconic acid, glutamic acid, glutaric acid, glycolic acid, hemisulfic acid, heptanoic acid, hexanoic acid, hippuric acid, hydrobromic acid, hydrochloric acid, hydroiodic acid, hydroxyethanesulfonic acid, lactic acid, maleic acid, malic acid, malonic acid, mandelic acid, methanesulfonic acid, mucic acid, naphthylanesulfonic acid, naphthylic acid, nicotinic acid, nitrous acid, oxalic acid, pelargonic, phosphoric acid, propionic acid, saccharin, salicylic acid, sorbic acid, succinic acid, sulfuric acid, tartaric acid, thiocyanic acid, thioglycolic acid, thiosulfuric acid, tosylic acid, undecylenic acid, naturally and synthetically derived amino acids. Non-limiting examples of base salts include ammonium salts; alkali metal salts, such as sodium and potassium salts; alkaline earth metal salts, such as calcium and magnesium salts; salts with organic bases, such as dicyclohexylamine salts; methyl-D-glucamine; and salts with amino acids, such as arginine, lysine, and so forth. Also, the basic nitrogen-containing groups can be quaternized with such agents as lower alkyl halides, such as methyl, ethyl, propyl, and butyl chlorides, bromides, and iodides; dialkyl sulfates, such as dimethyl, diethyl, dibutyl, and diamyl sulfates; long chain halides, such as decyl, lauryl, myristyl, and stearyl chlorides, bromides, and iodides; asthma halides, such as benzyl and phenethyl bromides; and others.

In formulations including an “additional,” “further,” or “second” component, the second component as used herein is chemically different from the other components or first component. A “third” component is different from the other, first, and second components, and further enumerated or “additional” components are similarly different.

The term “hydrophobic” is used herein in accordance with its plain ordinary meaning and refers to a chemical group having a tendency to attract non-polar or uncharged chemical groups, e.g. hexane, and to repel polar or charged chemical groups, e.g. water.

“Conjunctival hyperemia” or “red eye” refers to an ophthalmic condition caused by vasodilatation of the conjunctival blood vessels. The vasodilatation of the conjunctival blood vessels results in increased blood supply to the vessels or even rupture of the vessels, which causes redness of the eye, reduced visual acuity, severe ocular pain, and photophobia (light sensitivity). Conjunctival hyperemia is a common side effect caused by many topical glaucoma medications (e.g., bimatoprost or Lumigan®).

I. COMPOSITIONS

The present invention provides pharmaceutical compositions including a pharmaceutically active ingredient (e.g., two pharmaceutically active ingredients) and an ophthalmically acceptable excipient. In some embodiments, the pharmaceutical composition includes a prostaglandin agent and a vasoconstrictor agent. In some embodiments, the vasoconstrictor agent is present in a sub-therapeutic amount. The compositions provided herein may be used for the treatment of ophthalmic diseases. In some embodiments, the compositions are used for the treatment of increased intraocular pressure (IOP). Gels, aqueous solutions, emulsions, creams or ointments are contemplated as useful pharmaceutical formulations including the compositions provided herein.

In one aspect, a composition including a prostaglandin agent and a vasoconstrictor agent is provided. In some embodiments, the composition is an ophthalmic pharmaceutical formulation further including an ophthalmically acceptable excipient. Generally, ophthalmically acceptable excipients commonly known in the fields of ophthalmology and cosmetology as useful in topical compositions, and any non-toxic, inert, and effective topical carriers, are contemplated as useful in the compositions and products according to the embodiments of the present invention.

In some embodiments, the prostaglandin agent is present in a therapeutically effective amount. In other embodiments, the vasoconstrictor agent is present in a sub-therapeutic amount. As described above a sub-therapeutic amount is an amount of a therapeutic agent (e.g. drug), which is different to the clinically approved amount or concentration of that therapeutic agent. Thus, when a therapeutic agent (e.g. drug) is present at a sub-therapeutic amount it may be present at an amount that is less than the clinically approved amount for that therapeutic agent. In some embodiments, a sub-therapeutic amount of a therapeutic agent is less than the lowest clinically approved amount of that therapeutic agent.

Where the ophthalmic compositions provided herein include more than one active pharmaceutical ingredient, the active pharmaceutical ingredients are present in a combined amount effective to treat ophthalmic diseases. A combined effective amount is the total amount of active pharmaceutical ingredients that, in combination, provide an effective amount. For example, a combined effective amount may include a first amount of a first active pharmaceutical ingredient (e.g. a prostaglandin agent) and a second amount of a second active pharmaceutical ingredient (e.g. a vasoconstrictor agent). The first amount of the first active pharmaceutical ingredient may be less than an effective amount of the first active pharmaceutical ingredient when the first active pharmaceutical ingredient is administered without the second active pharmaceutical ingredient. On the other hand, the first amount of the first active pharmaceutical ingredient may be more than an effective amount of the first active pharmaceutical ingredient when the first active pharmaceutical ingredient is administered without the second active pharmaceutical ingredient. Correspondingly, the second amount of the second active pharmaceutical ingredient may be less than an effective amount of the second active pharmaceutical ingredient when the second active pharmaceutical ingredient is administered without the first active pharmaceutical ingredient. Equally, the second amount of the second active pharmaceutical ingredient may be more than an effective amount of the second active pharmaceutical ingredient when the second active pharmaceutical ingredient is administered without the first active pharmaceutical ingredient. Thus, in some embodiments, the prostaglandin agent and the vasoconstrictor agent are present in a combined amount effective to treat ophthalmic diseases.

The ophthalmic pharmaceutical compositions provided herein may be administered in various ways e.g., a foam, a gel, a cream, jelly, solution, suspension, a spray (e.g., a solution), an ointment, ointment films, occlusive films, sustained release films, fast drying films, slow drying films, patches, semi solids or stick formulation comprising a semi-solid vehicle with a melting point near physiological temperature. Topical compositions and products according to embodiments of the present invention can be formulated as creams, which can be semi-solid emulsions of oil and water, and lotions, including suspensions of powdered material in water or alcohol base and water-based emulsions. Topical compositions and products according to embodiments of the present invention can also be formulated as ointments, which are oleaginous and contain little if any water. In some embodiments, the ophthalmic pharmaceutical formulation is a gel formulation. In other embodiments, the ophthalmic pharmaceutical formulation is an aqueous formulation.

The compositions provided herein may include a prostaglandin agent and a vasoconstrictor agent as active pharmaceutical ingredients. It is also to be understood that pharmaceutically acceptable salts of the active pharmaceutical ingredients may be included in the compositions provided herein. A prostaglandin agent is a compound capable of binding a prostaglandin E₂ receptor. A prostaglandin E₂ receptor as defined herein is a G-protein coupled receptor that is being bound by prostaglandin E₂. Prostaglandin E₂ is a lipid mediator that is derived enzymatically from fatty acids and has important functions in the animal body. E₂ prostaglandins have a variety of strong physiological effects, such as regulating the contraction and relaxation of smooth muscle tissue. Non-limiting examples of prostaglandin agents contemplated for the compositions and methods provided herein are travoprost, latanoprost, unoprostone, tafluprost and bimatoprost. In some embodiments, the prostaglandin agent is bimatoprost. Bimatoprost refers, in the customary sense, to CAS Registry No. 155206-00-1. In some embodiments, bimatoprost is present in an amount approximately equal to or less than about 0.1% w/w. In some embodiments, bimatoprost is present from about 0.001 to about 0.1, from about 0.002 to about 0.1, from about 0.003 to about 0.1, from about 0.004 to about 0.1, from about 0.005 to about 0.1, from about 0.006 to about 0.1, from about 0.007 to about 0.1, from about 0.008 to about 0.1, from about 0.009 to about 0.1, from about 0.01 to about 0.1, from about 0.02 to about 0.1, from about 0.03 to about 0.1, from about 0.04 to about 0.1, from about 0.05 to about 0.1, from about 0.06 to about 0.1, from about 0.07 to about 0.1, from about 0.08 to about 0.1, from about 0.09 to about 0.1, from about 0.001 to about 0.08, from about 0.002 to about 0.08, from about 0.003 to about 0.08, from about 0.004 to about 0.08, from about 0.005 to about 0.08, from about 0.006 to about 0.08, from about 0.007 to about 0.08, from about 0.008 to about 0.08, from about 0.009 to about 0.08, from about 0.01 to about 0.08, from about 0.02 to about 0.08, from about 0.03 to about 0.08, from about 0.04 to about 0.08, from about 0.05 to about 0.08, from about 0.06 to about 0.08, from about 0.07 to about 0.08, from about 0.001 to about 0.06, from about 0.002 to about 0.06, from about 0.003 to about 0.06, from about 0.004 to about 0.06, from about 0.005 to about 0.06, from about 0.006 to about 0.06, from about 0.007 to about 0.06, from about 0.008 to about 0.06, from about 0.009 to about 0.06, from about 0.01 to about 0.06, from about 0.02 to about 0.06, from about 0.03 to about 0.06, from about 0.04 to about 0.06, from about 0.05 to about 0.06, from about 0.001 to about 0.04, from about 0.002 to about 0.04, from about 0.003 to about 0.04, from about 0.004 to about 0.04, from about 0.005 to about 0.04, from about 0.006 to about 0.04, from about 0.007 to about 0.04, from about 0.008 to about 0.04, from about 0.009 to about 0.04, from about 0.01 to about 0.04, from about 0.02 to about 0.04, from about 0.03 to about 0.04, from about 0.001 to about 0.02, from about 0.002 to about 0.02, from about 0.003 to about 0.02, from about 0.004 to about 0.02, from about 0.005 to about 0.02, from about 0.006 to about 0.02, from about 0.007 to about 0.02, from about 0.008 to about 0.02, from about 0.009 to about 0.02, from about 0.01 to about 0.02, from about 0.001 to about 0.01, from about 0.002 to about 0.01, from about 0.003 to about 0.01, from about 0.004 to about 0.01, from about 0.005 to about 0.01, from about 0.006 to about 0.01, from about 0.007 to about 0.01, from about 0.008 to about 0.01, or from about 0.009 to about 0.01% (w/w). In some embodiments, bimatoprost is present at about 0.001, 0.002, 0.003, 0.004, 0.005, 0.006, 0.007, 0.008, 0.009, 0.01, 0.02, 0.03, 0.04, 0.05, 0.06, 0.07, 0.08, 0.09, or 0.1% (w/w). In some embodiments, bimatoprost is present in an amount of about 0.03% w/w.

In other embodiments, the prostaglandin agent is travoprost. Travoprost refers, in the customary sense, to CAS Registry No. 157283-68-6. In some embodiments, the travoprost is present in an amount approximately equal to or less than about 0.1% w/w. In some embodiments, the travoprost is present in an amount from about 0.0002 to about 0.1, from about 0.0004 to about 0.1, from about 0.0006 to about 0.1, from about 0.0008 to about 0.1, from about 0.001 to about 0.1, from about 0.002 to about 0.1, from about 0.004 to about 0.1, from about 0.006 to about 0.1, from about 0.008 to about 0.1, from about 0.01 to about 0.1, from about 0.02 to about 0.1, from about 0.04 to about 0.1, from about 0.06 to about 0.1, from about 0.08 to about 0.1, from about 0.0002 to about 0.08, from about 0.0004 to about 0.08, from about 0.0006 to about 0.08, from about 0.0008 to about 0.08, from about 0.001 to about 0.08, from about 0.002 to about 0.08, from about 0.004 to about 0.08, from about 0.006 to about 0.08, from about 0.008 to about 0.08, from about 0.01 to about 0.08, from about 0.02 to about 0.08, from about 0.04 to about 0.08, from about 0.06 to about 0.08, from about 0.0002 to about 0.06, from about 0.0004 to about 0.06, from about 0.0006 to about 0.06, from about 0.0008 to about 0.06, from about 0.001 to about 0.06, from about 0.002 to about 0.06, from about 0.004 to about 0.06, from about 0.006 to about 0.06, from about 0.008 to about 0.06, from about 0.01 to about 0.06, from about 0.02 to about 0.06, from about 0.04 to about 0.06, from about 0.0002 to about 0.04, from about 0.0004 to about 0.04, from about 0.0006 to about 0.04, from about 0.0008 to about 0.04, from about 0.001 to about 0.04, from about 0.002 to about 0.04, from about 0.004 to about 0.04, from about 0.006 to about 0.04, from about 0.008 to about 0.04, from about 0.01 to about 0.04, from about 0.02 to about 0.04, from about 0.0002 to about 0.02, from about 0.0004 to about 0.02, from about 0.0006 to about 0.02, from about 0.0008 to about 0.02, from about 0.001 to about 0.02, from about 0.002 to about 0.02, from about 0.004 to about 0.02, from about 0.006 to about 0.02, from about 0.008 to about 0.02, from about 0.01 to about 0.02, from about 0.0002 to about 0.01, from about 0.0004 to about 0.01, from about 0.0006 to about 0.01, from about 0.0008 to about 0.01, from about 0.001 to about 0.01, from about 0.002 to about 0.01, from about 0.004 to about 0.01, from about 0.006 to about 0.01, from about 0.008 to about 0.01, from about 0.0002 to about 0.008, from about 0.0004 to about 0.008, from about 0.0006 to about 0.008, from about 0.0008 to about 0.008, from about 0.001 to about 0.008, from about 0.002 to about 0.008, from about 0.004 to about 0.008, from about 0.006 to about 0.008, from about 0.0002 to about 0.006, from about 0.0004 to about 0.006, from about 0.0006 to about 0.006, from about 0.0008 to about 0.006, from about 0.001 to about 0.006, from about 0.002 to about 0.006, from about 0.004 to about 0.006, from about 0.0002 to about 0.004, from about 0.0004 to about 0.004, from about 0.0006 to about 0.004, from about 0.0008 to about 0.004, from about 0.001 to about 0.004, from about 0.002 to about 0.004, from about 0.0002 to about 0.002, from about 0.0004 to about 0.002, from about 0.0006 to about 0.002, from about 0.0008 to about 0.002, from about 0.001 to about 0.002, from about 0.0002 to about 0.001, from about 0.0004 to about 0.001, from about 0.0006 to about 0.001, from about 0.0008 to about 0.001, from about 0.0002 to about 0.0008, from about 0.0004 to about 0.0008, from about 0.0006 to about 0.0008, from about 0.0002 to about 0.0006, from about 0.0004 to about 0.0006, or from about 0.0002 to about 0.0004% (w/w). In some embodiments, the travoprost is present at about 0.1, 0.08, 0.06, 0.04, 0.02, 0.01, 0.008, 0.006, 0.004, 0.002, 0.001, 0.0008, 0.0006, 0.0004, or 0.0002% (w/w). In some embodiments, travoprost is present in an amount of about 0.004% w/w.

In some embodiments, the prostaglandin agent is latanoprost. Latanoprost refers, in the customary sense, to CAS Registry No. 130209-82-4. In some embodiments, the latanoprost is present in an amount approximately equal to or less than about 0.1% w/w. In some embodiments, latanoprost is present from about 0.0003 to about 0.1, from about 0.0005 to about 0.1, from about 0.0007 to about 0.1, from about 0.0009 to about 0.1, from about 0.001 to about 0.1, from about 0.003 to about 0.1, from about 0.005 to about 0.1, from about 0.007 to about 0.1, from about 0.009 to about 0.1, from about 0.01 to about 0.1, from about 0.03 to about 0.1, from about 0.05 to about 0.1, from about 0.07 to about 0.1, from about 0.09 to about 0.1, from about 0.0003 to about 0.09, from about 0.0005 to about 0.09, from about 0.0007 to about 0.09, from about 0.0009 to about 0.09, from about 0.001 to about 0.09, from about 0.003 to about 0.09, from about 0.005 to about 0.09, from about 0.007 to about 0.09, from about 0.009 to about 0.09, from about 0.01 to about 0.09, from about 0.03 to about 0.09, from about 0.05 to about 0.09, from about 0.07 to about 0.09, from about 0.0003 to about 0.07, from about 0.0005 to about 0.07, from about 0.0007 to about 0.07, from about 0.0009 to about 0.07, from about 0.001 to about 0.07, from about 0.003 to about 0.07, from about 0.005 to about 0.07, from about 0.007 to about 0.07, from about 0.009 to about 0.07, from about 0.01 to about 0.07, from about 0.03 to about 0.07, from about 0.05 to about 0.07, from about 0.0003 to about 0.05, from about 0.0005 to about 0.05, from about 0.0007 to about 0.05, from about 0.0009 to about 0.05, from about 0.001 to about 0.05, from about 0.003 to about 0.05, from about 0.005 to about 0.05, from about 0.007 to about 0.05, from about 0.009 to about 0.05, from about 0.01 to about 0.05, from about 0.03 to about 0.05, from about 0.0003 to about 0.03, from about 0.0005 to about 0.03, from about 0.0007 to about 0.03, from about 0.0009 to about 0.03, from about 0.001 to about 0.03, from about 0.003 to about 0.03, from about 0.005 to about 0.03, from about 0.007 to about 0.03, from about 0.009 to about 0.03, from about 0.01 to about 0.03, from about 0.0003 to about 0.01, from about 0.0005 to about 0.01, from about 0.0007 to about 0.01, from about 0.0009 to about 0.01, from about 0.001 to about 0.01, from about 0.003 to about 0.01, from about 0.005 to about 0.01, from about 0.007 to about 0.01, from about 0.009 to about 0.01, from about 0.0003 to about 0.009, from about 0.0005 to about 0.009, from about 0.0007 to about 0.009, from about 0.0009 to about 0.009, from about 0.001 to about 0.009, from about 0.003 to about 0.009, from about 0.005 to about 0.009, from about 0.007 to about 0.009, from about 0.0003 to about 0.007, from about 0.0005 to about 0.007, from about 0.0007 to about 0.007, from about 0.0009 to about 0.007, from about 0.001 to about 0.007, from about 0.003 to about 0.007, from about 0.005 to about 0.007, from about 0.0003 to about 0.005, from about 0.0005 to about 0.005, from about 0.0007 to about 0.005, from about 0.0009 to about 0.005, from about 0.001 to about 0.005, from about 0.003 to about 0.005, from about 0.0003 to about 0.003, from about 0.0005 to about 0.003, from about 0.0007 to about 0.003, from about 0.0009 to about 0.003, from about 0.001 to about 0.003, from about 0.0003 to about 0.001, from about 0.0005 to about 0.001, from about 0.0007 to about 0.001, from about 0.0009 to about 0.001, from about 0.0003 to about 0.0009, from about 0.0005 to about 0.0009, from about 0.0007 to about 0.0009, from about 0.0003 to about 0.0007, from about 0.0005 to about 0.0007, or from about 0.0003 to about 0.0005% (w/w). In some embodiments, the latanoprost is present at about 0.1, 0.09, 0.07, 0.05, 0.03, 0.01, 0.009, 0.007, 0.005, 0.003, 0.001, 0.0009, 0.0007, 0.0005, or 0.0003% (w/w). In some embodiments, the latanoprost is present in an amount of about 0.005% w/w.

As mentioned above the ophthalmic pharmaceutical formulations provided herein may include a vasoconstrictor agent. A vasoconstrictor agent is an agent having a vasoconstriction effect on blood vessels. Vasoconstriction is the narrowing of blood vessels resulting from contraction of the muscular wall of the vessels. Vasoconstriction is a mechanism by which the body regulates and maintains mean arterial pressure. Therefore, vasoconstrictors or vasoconstrictor agents are agents causing a general increase in systemic blood pressure, but at the same time may cause a localized reduction in blood flow. In some embodiments, the vasoconstrictor agent is an alpha adrenergic agonist. An alpha adrenergic agonist is an agent (e.g., drug, compound), which selectively stimulates alpha adrenergic receptors. Alpha adrenergic receptors are G protein-coupled receptors that are bound by noradrenalin and adrenaline. Binding of an agonist to an alpha adrenergic receptor leads to vasoconstriction, which causes a sympathetic response, where the heart rate increases, the pupils dilate and blood flow is being diverted from non-essential organs to the skeletal muscle. A non-limiting example of an alpha adrenergic agonist is brimonidine. Brimonidine refers, in the customary sense, to CAS Registry No. 59803-98-4. In some embodiments, the alpha adrenergic agonist is brimonidine.

In other embodiments, the vasoconstrictor agent is a beta adrenergic antagonist. A beta adrenergic antagonist is an agent (e.g., drug, compound), which blocks the stimulation of beta adrenergic receptors. Stimulation of beta adrenergic receptors induces smooth muscle relaxation, whereas blocking beta adrenergic receptors causes contraction of smooth muscles. Therefore, beta adrenergic antagonists can cause vasoconstriction. Examples of beta adrenergic antagonists are without limitation befunolol, betaxolol, carteolol, levobunolol, metipranolol, timolol, and mepindolol.

In some embodiments, the beta adrenergic antagonist is timolol. In some embodiments, the timolol is timolol maleate. Timolol maleate refers, in the customary sense, to CAS Registry No. 26839-75-8. The chemical name of timolol maleate is (−)-1-tert-butylamino-3-[(4-morpholino-1,2,5-thiodiazol-3yl)oxy]-2-propanol maleate. Timolol maleate has a molecular weight of 432.50 g/mol and is commercially available from Merck as TIMOPTIC®. In other embodiments, the timolol is timolol hemihydrate. In some embodiments, the timolol is present in a sub-therapeutic amount. In some embodiments, the sub-therapeutic amount is an amount less than about 0.25% w/w. In some embodiments, the sub-therapeutic amount is an amount from about 0.0002 to about 0.25, from about 0.0004 to about 0.25, from about 0.0006 to about 0.25, from about 0.0008 to about 0.25, from about 0.001 to about 0.25, from about 0.002 to about 0.25, from about 0.004 to about 0.25, from about 0.006 to about 0.25, from about 0.008 to about 0.25, from about 0.01 to about 0.25, from about 0.02 to about 0.25, from about 0.04 to about 0.25, from about 0.06 to about 0.25, from about 0.08 to about 0.25, from about 0.1 to about 0.25, from about 0.15 to about 0.25, from about 0.20 to about 0.25, from about 0.0002 to about 0.20, from about 0.0004 to about 0.20, from about 0.0006 to about 0.20, from about 0.0008 to about 0.20, from about 0.001 to about 0.20, from about 0.002 to about 0.20, from about 0.004 to about 0.20, from about 0.006 to about 0.20, from about 0.008 to about 0.20, from about 0.01 to about 0.20, from about 0.02 to about 0.20, from about 0.04 to about 0.20, from about 0.06 to about 0.20, from about 0.08 to about 0.20, from about 0.1 to about 0.20, from about 0.15 to about 0.20, from about 0.0002 to about 0.015, from about 0.0004 to about 0.015, from about 0.0006 to about 0.015, from about 0.0008 to about 0.015, from about 0.001 to about 0.015, from about 0.002 to about 0.015, from about 0.004 to about 0.015, from about 0.006 to about 0.015, from about 0.008 to about 0.015, from about 0.01 to about 0.15, from about 0.02 to about 0.15, from about 0.04 to about 0.15, from about 0.06 to about 0.15, from about 0.08 to about 0.15, from about 0.1 to about 0.15, from about 0.0002 to about 0.001, from about 0.0004 to about 0.001, from about 0.0006 to about 0.001, from about 0.0008 to about 0.001, from about 0.001 to about 0.01, from about 0.002 to about 0.01, from about 0.004 to about 0.01, from about 0.006 to about 0.01, from about 0.008 to about 0.01, from about 0.01 to about 0.1, from about 0.02 to about 0.1, from about 0.04 to about 0.1, from about 0.06 to about 0.1, from about 0.08 to about 0.1, from about 0.0002 to about 0.08, from about 0.0004 to about 0.08, from about 0.0006 to about 0.08, from about 0.0008 to about 0.08, from about 0.001 to about 0.08, from about 0.002 to about 0.08, from about 0.004 to about 0.08, from about 0.006 to about 0.08, from about 0.008 to about 0.08, from about 0.01 to about 0.08, from about 0.02 to about 0.08, from about 0.04 to about 0.08, from about 0.06 to about 0.08, from about 0.0002 to about 0.06, from about 0.0004 to about 0.06, from about 0.0006 to about 0.06, from about 0.0008 to about 0.06, from about 0.001 to about 0.06, from about 0.002 to about 0.06, from about 0.004 to about 0.06, from about 0.006 to about 0.06, from about 0.008 to about 0.06, from about 0.01 to about 0.06, from about 0.02 to about 0.06, from about 0.04 to about 0.06, from about 0.0002 to about 0.04, from about 0.0004 to about 0.04, from about 0.0006 to about 0.04, from about 0.0008 to about 0.04, from about 0.001 to about 0.04, from about 0.002 to about 0.04, from about 0.004 to about 0.04, from about 0.006 to about 0.04, from about 0.008 to about 0.04, from about 0.01 to about 0.04, from about 0.02 to about 0.04, from about 0.0002 to about 0.02, from about 0.0004 to about 0.02, from about 0.0006 to about 0.02, from about 0.0008 to about 0.02, from about 0.001 to about 0.02, from about 0.002 to about 0.02, from about 0.004 to about 0.02, from about 0.006 to about 0.02, from about 0.008 to about 0.02, from about 0.01 to about 0.02, from about 0.0002 to about 0.01, from about 0.0004 to about 0.01, from about 0.0006 to about 0.01, from about 0.0008 to about 0.01, from about 0.001 to about 0.01, from about 0.002 to about 0.01, from about 0.004 to about 0.01, from about 0.006 to about 0.01, from about 0.008 to about 0.01, from about 0.0002 to about 0.008, from about 0.0004 to about 0.008, from about 0.0006 to about 0.008, from about 0.0008 to about 0.008, from about 0.001 to about 0.008, from about 0.002 to about 0.008, from about 0.004 to about 0.008, from about 0.006 to about 0.008, from about 0.0002 to about 0.006, from about 0.0004 to about 0.006, from about 0.0006 to about 0.006, from about 0.0008 to about 0.006, from about 0.001 to about 0.006, from about 0.002 to about 0.006, from about 0.004 to about 0.006, from about 0.0002 to about 0.004, from about 0.0004 to about 0.004, from about 0.0006 to about 0.004, from about 0.0008 to about 0.004, from about 0.001 to about 0.004, from about 0.002 to about 0.004, from about 0.0002 to about 0.002, from about 0.0004 to about 0.002, from about 0.0006 to about 0.002, from about 0.0008 to about 0.002, from about 0.001 to about 0.002, from about 0.0002 to about 0.001, from about 0.0004 to about 0.001, from about 0.0006 to about 0.001, from about 0.0008 to about 0.001, from about 0.0002 to about 0.0008, from about 0.0004 to about 0.0008, from about 0.0006 to about 0.0008, from about 0.0002 to about 0.0006, from about 0.0004 to about 0.0006, or from about 0.0002 to about 0.0004% (w/w). In other embodiments, the sub-therapeutic amount is an amount of about 0.0002, 0.0004, 0.0006, 0.0008, 0.001, 0.002, 0.004, 0.006, 0.008, 0.01, 0.02, 0.04, 0.06, 0.08, 0.1, 0.15, 0.20, or 0.25% (w/w).

In other embodiments, beta adrenergic antagonist is betaxolol. In some embodiments, the betaxolol is present in a sub-therapeutic amount. Betaxolol refers, in the customary sense, to CAS Registry No. 63659-18-7. In some embodiments, the sub-therapeutic amount is an amount less than about 0.25% w/w. In some embodiments, the sub-therapeutic amount is an amount from about 0.0002 to about 0.25, from about 0.0004 to about 0.25, from about 0.0006 to about 0.25, from about 0.0008 to about 0.25, from about 0.001 to about 0.25, from about 0.002 to about 0.25, from about 0.004 to about 0.25, from about 0.006 to about 0.25, from about 0.008 to about 0.25, from about 0.01 to about 0.25, from about 0.02 to about 0.25, from about 0.04 to about 0.25, from about 0.06 to about 0.25, from about 0.08 to about 0.25, from about 0.1 to about 0.25, from about 0.15 to about 0.25, from about 0.20 to about 0.25, from about 0.0002 to about 0.20, from about 0.0004 to about 0.20, from about 0.0006 to about 0.20, from about 0.0008 to about 0.20, from about 0.001 to about 0.20, from about 0.002 to about 0.20, from about 0.004 to about 0.20, from about 0.006 to about 0.20, from about 0.008 to about 0.20, from about 0.01 to about 0.20, from about 0.02 to about 0.20, from about 0.04 to about 0.20, from about 0.06 to about 0.20, from about 0.08 to about 0.20, from about 0.1 to about 0.20, from about 0.15 to about 0.20, from about 0.0002 to about 0.15, from about 0.0004 to about 0.15, from about 0.0006 to about 0.15, from about 0.0008 to about 0.15, from about 0.001 to about 0.15, from about 0.002 to about 0.15, from about 0.004 to about 0.15, from about 0.006 to about 0.15, from about 0.008 to about 0.15, from about 0.01 to about 0.15, from about 0.02 to about 0.15, from about 0.04 to about 0.15, from about 0.06 to about 0.15, from about 0.08 to about 0.15, from about 0.1 to about 0.15, from about 0.0002 to about 0.1, from about 0.0004 to about 0.1, from about 0.0006 to about 0.1, from about 0.0008 to about 0.1, from about 0.001 to about 0.1, from about 0.002 to about 0.1, from about 0.004 to about 0.1, from about 0.006 to about 0.1, from about 0.008 to about 0.1, from about 0.01 to about 0.1, from about 0.02 to about 0.1, from about 0.04 to about 0.1, from about 0.06 to about 0.1, from about 0.08 to about 0.1, from about 0.0002 to about 0.08, from about 0.0004 to about 0.08, from about 0.0006 to about 0.08, from about 0.0008 to about 0.08, from about 0.001 to about 0.08, from about 0.002 to about 0.08, from about 0.004 to about 0.08, from about 0.006 to about 0.08, from about 0.008 to about 0.08, from about 0.01 to about 0.08, from about 0.02 to about 0.08, from about 0.04 to about 0.08, from about 0.06 to about 0.08, from about 0.0002 to about 0.06, from about 0.0004 to about 0.06, from about 0.0006 to about 0.06, from about 0.0008 to about 0.06, from about 0.001 to about 0.06, from about 0.002 to about 0.06, from about 0.004 to about 0.06, from about 0.006 to about 0.06, from about 0.008 to about 0.06, from about 0.01 to about 0.06, from about 0.02 to about 0.06, from about 0.04 to about 0.06, from about 0.0002 to about 0.04, from about 0.0004 to about 0.04, from about 0.0006 to about 0.04, from about 0.0008 to about 0.04, from about 0.001 to about 0.04, from about 0.002 to about 0.04, from about 0.004 to about 0.04, from about 0.006 to about 0.04, from about 0.008 to about 0.04, from about 0.01 to about 0.04, from about 0.02 to about 0.04, from about 0.0002 to about 0.02, from about 0.0004 to about 0.02, from about 0.0006 to about 0.02, from about 0.0008 to about 0.02, from about 0.001 to about 0.02, from about 0.002 to about 0.02, from about 0.004 to about 0.02, from about 0.006 to about 0.02, from about 0.008 to about 0.02, from about 0.01 to about 0.02, from about 0.0002 to about 0.01, from about 0.0004 to about 0.01, from about 0.0006 to about 0.01, from about 0.0008 to about 0.01, from about 0.001 to about 0.01, from about 0.002 to about 0.01, from about 0.004 to about 0.01, from about 0.006 to about 0.01, from about 0.008 to about 0.01, from about 0.0002 to about 0.008, from about 0.0004 to about 0.008, from about 0.0006 to about 0.008, from about 0.0008 to about 0.008, from about 0.001 to about 0.008, from about 0.002 to about 0.008, from about 0.004 to about 0.008, from about 0.006 to about 0.008, from about 0.0002 to about 0.006, from about 0.0004 to about 0.006, from about 0.0006 to about 0.006, from about 0.0008 to about 0.006, from about 0.001 to about 0.006, from about 0.002 to about 0.006, from about 0.004 to about 0.006, from about 0.0002 to about 0.004, from about 0.0004 to about 0.004, from about 0.0006 to about 0.004, from about 0.0008 to about 0.004, from about 0.001 to about 0.004, from about 0.002 to about 0.004, from about 0.0002 to about 0.002, from about 0.0004 to about 0.002, from about 0.0006 to about 0.002, from about 0.0008 to about 0.002, from about 0.001 to about 0.002, from about 0.0002 to about 0.001, from about 0.0004 to about 0.001, from about 0.0006 to about 0.001, from about 0.0008 to about 0.001, from about 0.0002 to about 0.0008, from about 0.0004 to about 0.0008, from about 0.0006 to about 0.0008, from about 0.0002 to about 0.0006, from about 0.0004 to about 0.0006, or from about 0.0002 to about 0.0004% (w/w). In other embodiments, the sub-therapeutic amount is an amount of about 0.0002, 0.0004, 0.0006, 0.0008, 0.001, 0.002, 0.004, 0.006, 0.008, 0.01, 0.02, 0.04, 0.06, 0.08, 0.1, 0.15, 0.20, or 0.25% (w/w). In some embodiments, the betaxolol is a betaxolol salt.

In other embodiments, the beta adrenergic antagonist is levobunolol. Levobunolol refers, in the customary sense, to CAS Registry No. 47141-42-4. In some embodiments, the levobunolol is present in a sub-therapeutic amount. In some embodiments, the sub-therapeutic amount is an amount less than about 0.25% w/w. In some embodiments, the sub-therapeutic amount is an amount from about 0.0002 to about 0.25, from about 0.0004 to about 0.25, from about 0.0006 to about 0.25, from about 0.0008 to about 0.25, from about 0.001 to about 0.25, from about 0.002 to about 0.25, from about 0.004 to about 0.25, from about 0.006 to about 0.25, from about 0.008 to about 0.25, from about 0.01 to about 0.25, from about 0.02 to about 0.25, from about 0.04 to about 0.25, from about 0.06 to about 0.25, from about 0.08 to about 0.25, from about 0.1 to about 0.25, from about 0.15 to about 0.25, from about 0.20 to about 0.25, from about 0.0002 to about 0.20, from about 0.0004 to about 0.20, from about 0.0006 to about 0.20, from about 0.0008 to about 0.20, from about 0.001 to about 0.20, from about 0.002 to about 0.20, from about 0.004 to about 0.20, from about 0.006 to about 0.20, from about 0.008 to about 0.20, from about 0.01 to about 0.20, from about 0.02 to about 0.20, from about 0.04 to about 0.20, from about 0.06 to about 0.20, from about 0.08 to about 0.20, from about 0.1 to about 0.20, from about 0.15 to about 0.20, from about 0.0002 to about 0.15, from about 0.0004 to about 0.15, from about 0.0006 to about 0.15, from about 0.0008 to about 0.15, from about 0.001 to about 0.15, from about 0.002 to about 0.15, from about 0.004 to about 0.15, from about 0.006 to about 0.15, from about 0.008 to about 0.15, from about 0.01 to about 0.15, from about 0.02 to about 0.15, from about 0.04 to about 0.15, from about 0.06 to about 0.15, from about 0.08 to about 0.15, from about 0.1 to about 0.15, from about 0.0002 to about 0.1, from about 0.0004 to about 0.1, from about 0.0006 to about 0.1, from about 0.0008 to about 0.1, from about 0.001 to about 0.1, from about 0.002 to about 0.1, from about 0.004 to about 0.1, from about 0.006 to about 0.1, from about 0.008 to about 0.1, from about 0.01 to about 0.1, from about 0.02 to about 0.1, from about 0.04 to about 0.1, from about 0.06 to about 0.1, from about 0.08 to about 0.1, from about 0.0002 to about 0.08, from about 0.0004 to about 0.08, from about 0.0006 to about 0.08, from about 0.0008 to about 0.08, from about 0.001 to about 0.08, from about 0.002 to about 0.08, from about 0.004 to about 0.08, from about 0.006 to about 0.08, from about 0.008 to about 0.08, from about 0.01 to about 0.08, from about 0.02 to about 0.08, from about 0.04 to about 0.08, from about 0.06 to about 0.08, from about 0.0002 to about 0.06, from about 0.0004 to about 0.06, from about 0.0006 to about 0.06, from about 0.0008 to about 0.06, from about 0.001 to about 0.06, from about 0.002 to about 0.06, from about 0.004 to about 0.06, from about 0.006 to about 0.06, from about 0.008 to about 0.06, from about 0.01 to about 0.06, from about 0.02 to about 0.06, from about 0.04 to about 0.06, from about 0.0002 to about 0.04, from about 0.0004 to about 0.04, from about 0.0006 to about 0.04, from about 0.0008 to about 0.04, from about 0.001 to about 0.04, from about 0.002 to about 0.04, from about 0.004 to about 0.04, from about 0.006 to about 0.04, from about 0.008 to about 0.04, from about 0.01 to about 0.04, from about 0.02 to about 0.04, from about 0.0002 to about 0.02, from about 0.0004 to about 0.02, from about 0.0006 to about 0.02, from about 0.0008 to about 0.02, from about 0.001 to about 0.02, from about 0.002 to about 0.02, from about 0.004 to about 0.02, from about 0.006 to about 0.02, from about 0.008 to about 0.02, from about 0.01 to about 0.02, from about 0.0002 to about 0.01, from about 0.0004 to about 0.01, from about 0.0006 to about 0.01, from about 0.0008 to about 0.01, from about 0.001 to about 0.01, from about 0.002 to about 0.01, from about 0.004 to about 0.01, from about 0.006 to about 0.01, from about 0.008 to about 0.01, from about 0.0002 to about 0.008, from about 0.0004 to about 0.008, from about 0.0006 to about 0.008, from about 0.0008 to about 0.008, from about 0.001 to about 0.008, from about 0.002 to about 0.008, from about 0.004 to about 0.008, from about 0.006 to about 0.008, from about 0.0002 to about 0.006, from about 0.0004 to about 0.006, from about 0.0006 to about 0.006, from about 0.0008 to about 0.006, from about 0.001 to about 0.006, from about 0.002 to about 0.006, from about 0.004 to about 0.006, from about 0.0002 to about 0.004, from about 0.0004 to about 0.004, from about 0.0006 to about 0.004, from about 0.0008 to about 0.004, from about 0.001 to about 0.004, from about 0.002 to about 0.004, from about 0.0002 to about 0.002, from about 0.0004 to about 0.002, from about 0.0006 to about 0.002, from about 0.0008 to about 0.002, from about 0.001 to about 0.002, from about 0.0002 to about 0.001, from about 0.0004 to about 0.001, from about 0.0006 to about 0.001, from about 0.0008 to about 0.001, from about 0.0002 to about 0.0008, from about 0.0004 to about 0.0008, from about 0.0006 to about 0.0008, from about 0.0002 to about 0.0006, from about 0.0004 to about 0.0006, or from about 0.0002 to about 0.0004% (w/w). In other embodiments, the sub-therapeutic amount is an amount of about 0.0002, 0.0004, 0.0006, 0.0008, 0.001, 0.002, 0.004, 0.006, 0.008, 0.01, 0.02, 0.04, 0.06, 0.08, 0.1, 0.15, 0.20, or 0.25% (w/w). In some embodiments, the levobunolol is a levobunolol salt.

In other embodiments, the beta adrenergic antagonist is metipranolol. Metipranolol refers, in the customary sense, to CAS Registry No. 22664-55-7. In some embodiments, the metipranolol is present in a sub-therapeutic amount. In some embodiments, the sub-therapeutic amount is an amount less than about 0.3% w/w. In some embodiments, the sub-therapeutic amount is an amount from about 0.003 to about 0.3, from about 0.004 to about 0.3, from about 0.006 to about 0.3, from about 0.008 to about 0.3, from about 0.01 to about 0.3, from about 0.03 to about 0.3, from about 0.04 to about 0.3, from about 0.06 to about 0.3, from about 0.08 to about 0.3, from about 0.1 to about 0.3, from about 0.15 to about 0.3, from about 0.20 to about 0.3, from about 0.25 to about 0.3, from about 0.003 to about 0.25, from about 0.004 to about 0.25, from about 0.006 to about 0.25, from about 0.008 to about 0.25, from about 0.01 to about 0.25, from about 0.03 to about 0.25, from about 0.04 to about 0.25, from about 0.06 to about 0.25, from about 0.08 to about 0.25, from about 0.1 to about 0.25, from about 0.15 to about 0.25, from about 0.20 to about 0.25, from about 0.003 to about 0.20, from about 0.004 to about 0.20, from about 0.006 to about 0.20, from about 0.008 to about 0.20, from about 0.01 to about 0.20, from about 0.03 to about 0.20, from about 0.04 to about 0.20, from about 0.06 to about 0.20, from about 0.08 to about 0.20, from about 0.1 to about 0.20, from about 0.15 to about 0.20, from about 0.003 to about 0.15, from about 0.004 to about 0.15, from about 0.006 to about 0.15, from about 0.008 to about 0.15, from about 0.01 to about 0.15, from about 0.03 to about 0.15, from about 0.04 to about 0.15, from about 0.06 to about 0.15, from about 0.08 to about 0.15, from about 0.1 to about 0.15, from about 0.003 to about 0.1, from about 0.004 to about 0.1, from about 0.006 to about 0.1, from about 0.008 to about 0.1, from about 0.01 to about 0.1, from about 0.03 to about 0.1, from about 0.04 to about 0.1, from about 0.06 to about 0.1, from about 0.08 to about 0.1, from about 0.003 to about 0.08, from about 0.004 to about 0.08, from about 0.006 to about 0.08, from about 0.008 to about 0.08, from about 0.01 to about 0.08, from about 0.03 to about 0.08, from about 0.04 to about 0.08, from about 0.06 to about 0.08, from about 0.003 to about 0.06, from about 0.004 to about 0.06, from about 0.006 to about 0.06, from about 0.008 to about 0.06, from about 0.01 to about 0.06, from about 0.03 to about 0.06, from about 0.04 to about 0.06, from about 0.003 to about 0.04, from about 0.004 to about 0.04, from about 0.006 to about 0.04, from about 0.008 to about 0.04, from about 0.01 to about 0.04, from about 0.03 to about 0.04, from about 0.003 to about 0.03, from about 0.004 to about 0.03, from about 0.006 to about 0.03, from about 0.008 to about 0.03, from about 0.01 to about 0.03, from about 0.003 to about 0.01, from about 0.004 to about 0.01, from about 0.006 to about 0.01, from about 0.008 to about 0.01, from about 0.003 to about 0.008, from about 0.004 to about 0.008, from about 0.006 to about 0.008, from about 0.003 to about 0.006, from about 0.004 to about 0.006, or from about 0.003 to about 0.004% (w/w). In other embodiments, the sub-therapeutic amount is an amount of about 0.3, 0.25, 0.20, 0.15, 0.1, 0.08, 0.06, 0.04, 0.03, 0.01, 0.008, 0.006, 0.004, or 0.003% (w/w). In some embodiments, the metipranolol is a metipranolol salt.

The compositions and products according to the embodiments of the present invention may include a buffering agent, a tonicity agent, a salt, a thickening agent or a preservative. In some embodiments, the composition includes a buffering agent, a tonicity agent, a salt, a thickening agent and a preservative.

A buffering agents are means for adjusting the pH of the compositions provided to be an ophthalmically acceptable pH (e.g. neutral pH). Buffers appropriate to for the compositions provided include acetate buffers, citrate buffers, phosphate buffers and borate buffers. Acids or bases may also be used to adjust the pH of the ophthalmic formulations as needed. The pH of the disclosed compositions should preferably be maintained between 6.5 and 7.2 with an appropriate buffering agent.

The term “tonicity agent” as used herein refers to a compound or ion useful for adjusting the osmotic pressure or tension of a solution, often relative to that of blood. Examples for tonicity agents are without limitation, glycerin, erythritol, mannitol, potassium, chloride, and sodium chloride. In some embodiments, the tonicity agent is glycerin. In some further embodiments, the tonicity agent is present from about 0.5% w/w to about 6% w/w.

The formulation's viscosity is a factor that determines how well the formulation sticks to the skin or ophthalmic tissue or does not run off the skin or ophthalmic tissue when applied. The viscosity of the formulation can be optimized using one or more pharmaceutically acceptable thickening agents that do not significantly interact with the components of the formulation, do not significantly reduce flux of the formulation, and do not cause stinging or irritation. Non-limiting examples of suitable thickeners useful herein include cellulosic polymers, such as gum arabic, gum acacia, gum tragacanth, locust bean gum, guar gum, hydroxypropyl guar, xanthan gum, talc, cellulose gum, sclerotium gum, carageenan gum, karaya gum, cellulose gum, rosin, methylcellulose, hydroxyethylcellulose, hydroxypropylcellulose, hydroxymethylcellulosf, hydroxypropylmethylcellulose, methylhydroxyethylcellulose, cetyl hydroxyethylcellulose, carboxymethylcellulose, corn starch, hydroxypropyl starch phosphate, distarch phosphate, distarch dimethylene urea, aluminum starch octenyl succinate, maltodextrin, dextran, poly(acrylamide), PEG-150 distearate, PEG-150/decyl alcohol/SMDI copolymer, PEG-150/stearyl alcohol/SMDI copolymer, PEG-180/Laureth-50/TMMG copolymer, Polyether 1, acrylic acid/acrylamidomethyl propane sulfonic acid copolymer, acrylate/C10-30 alkyl acrylate cross polymer, acrylate/beheneth-25 methacrylate copolymer, acrylate/steareth-20 methacrylate copolymer, acrylate/steareth-20 copolymer, acrylate/VA cross polymer, acrylic acid/acrylonitrogen copolymer, ammonium acryloyldimethyltaurate/beheneth-25 methacrylate copolymer, ammonium acryloyldimethyltaurate/VP copolymer, caprylic/capric triglyceride (and) sodium acrylate copolymer, PVM/MA decadiene cross polymer, alginic acid, propylene glycol alginate, dimethicone, silica dimethyl silylate, a dimethylacrylamide/acrylic acid/polystyrene ethyl methacrylate copolymer, derivatives thereof, and mixtures thereof.

Preservatives that can be used in the ophthalmic pharmaceutical formulations of the present embodiments include, but are not limited to, benzalkonium chloride, chlorobutanol, thimerosal, phenylmercuric acetate and phenylmercuric nitrate. Preservative-free compositions can be considered, for example for patients experiencing hypersensitivity reactions with the above listed preservatives or other preservatives not listed. Thus, in some embodiments, the composition further includes a buffering agent, a tonicity agent, a salt and a thickening agent.

In some embodiments, the composition consists essentially of bimatoprost, timolol, a buffering agent, a tonicity agent, a salt, a thickening agent and a preservative. Where the composition consists essentially of bimatoprost, timolol, a buffering agent, a tonicity agent, a salt, a thickening agent and a preservative, the composition consists of bimatoprost and timolol, and any appropriate buffering agent, tonicity agent, salt, thickening agent and preservative. In some embodiments, the timolol is present in a sub-therapeutic amount. As described earlier the sub-therapeutic amount may be an amount less than about 0.25% w/w. Thus, in some embodiments, the sub-therapeutic amount is an amount of about 0.0002, 0.0004, 0.0006, 0.0008, 0.001, 0.002, 0.004, 0.006, 0.008, 0.01, 0.02, 0.04, 0.06, 0.08, 0.1, 0.15, 0.20, or 0.25% (w/w).

The compositions provided herein may consist essentially of bimatoprost, a beta adrenergic antagonist, buffering agent, a tonicity agent, a salt, a thickening agent and a preservative. Where the compositions provided herein may consist essentially of bimatoprost, a beta adrenergic antagonist, buffering agent, a tonicity agent, a salt, a thickening agent and a preservative, the composition consists of bimatoprost and a beta adrenergic antagonist, and any appropriate buffering agent, tonicity agent, salt, thickening agent and preservative. In some embodiments, the beta adrenergic antagonist is present in a sub-therapeutic amount. Non-limiting examples of a beta adrenergic compound suitable for the compositions and methods according to the embodiments of the present invention are betaxolol, levobunolol, or metipranolol. Thus, in some embodiments, the composition consists essentially of bimatoprost, betaxolol, a buffering agent, a tonicity agent, a salt, a preservative and a thickening agent. In some further embodiments, the betaxolol is present in a sub-therapeutic amount. In further embodiments, the sub-therapeutic amount is an amount less than about 0.25% w/w.

In other embodiments, the composition consists essentially of bimatoprost, levobunolol, a buffering agent, a tonicity agent, a salt, a preservative and a thickening agent. In further embodiments, the levobunolol is present in a sub-therapeutic amount. In some further embodiment, the sub-therapeutic amount is an amount less than about 0.25% w/w.

In some embodiments, the composition consists essentially of bimatoprost, metipranolol, a buffering agent, a tonicity agent, a salt, a preservative and a thickening agent. In further embodiments, the metipranolol is present in a sub-therapeutic amount. In some further embodiment, the sub-therapeutic amount is an amount less than about 0.3% w/w.

Tables 1-12 describe various examples of combinations of effective amounts of the prostaglandin agent (e.g., bimatoprost, travoprost, latanoprost) and the vasoconstrictor agent (e.g., timolol, betaxolol, levobunolol, metipranolol, tetrahydrozoline hydrochloride, brimonidine etc.). In particular, Table 1 provides 342 different combination embodiments of bimatoprost, as shown in the first column labeled “Bimatoprost % w/w”, and timolol, as shown in the first row labeled “Timolol % w/w.” Specific concentrations of bimatoprost and timolol for each of the combination embodiments described in Table 1 and numbered from 1 to 19 are shown, respectively, in the cells in the first row, which correspond to the numbered cell.

Table 2 provides 342 different combination embodiments of bimatoprost, as shown in the first column labeled “Bimatoprost % w/w”, and betaxolol as shown in the first row labeled “Betaxolol % w/w.” Specific concentrations of bimatoprost and betaxolol for each of the combination embodiments described in Table 2 and numbered from 343 to 361 are shown, respectively, in the cells in the first row, which correspond to the numbered cell.

Table 3 provides 342 different combination embodiments of bimatoprost, as shown in the first column labeled “Bimatoprost % w/w”, and levobunolol as shown in the first row labeled “Levobunolol % w/w.” Specific concentrations of bimatoprost and levobunolol for each of the combination embodiments described in Table 3 and numbered from 685 to 703 are shown, respectively, in the cells in the first row, which correspond to the numbered cell.

Table 4 provides 266 different combination embodiments of bimatoprost, as shown in the first column labeled “Bimatoprost % w/w”, and metipranolol as shown in the first row labeled “Metipranolol % w/w.” Specific concentrations of bimatoprost and metipranolol for each of the combination embodiments described in Table 4 and numbered from 1027 to 1045 are shown, respectively, in the cells in the first row, which correspond to the numbered cell.

Table 5 provides 270 different combination embodiments of travoprost, as shown in the first column labeled “Travoprost % w/w”, and timolol, as shown in the first row labeled “Timolol % w/w.” Specific concentrations of travoprost and timolol for each of the combination embodiments described in Table 5 and numbered from 1293 to 1307 are shown, respectively, in the cells in the first row, which correspond to the numbered cell.

Table 6 provides 270 different combination embodiments of travoprost, as shown in the first column labeled “Travoprost % w/w”, and betaxolol as shown in the first row labeled “Betaxolol % w/w.” Specific concentrations of travoprost and betaxolol for each of the combination embodiments described in Table 6 and numbered from 1563 to 1577 are shown, respectively, in the cells in the first row, which correspond to the numbered cell.

Table 7 provides 270 different combination embodiments of travoprost, as shown in the first column labeled “Travoprost % w/w”, and levobunolol as shown in the first row labeled “Levobunolol % w/w.” Specific concentrations of travoprost and levobunolol for each of the combination embodiments described in Table 7 and numbered from 1833 to 1847 are shown, respectively, in the cells in the first row, which correspond to the numbered cell.

Table 8 provides 210 different combination embodiments of travoprost, as shown in the first column labeled “Travoprost % w/w”, and metipranolol as shown in the first row labeled “Metipranolol % w/w.” Specific concentrations of travoprost and metipranolol for each of the combination embodiments described in Table 8 and numbered from 2103 to 2117 are shown, respectively, in the cells in the first row, which correspond to the numbered cell.

Table 9 provides 270 different combination embodiments of latanoprost, as shown in the first column labeled “Latanoprost % w/w”, and timolol, as shown in the first row labeled “Timolol % w/w.” Specific concentrations of latanoprost and timolol for each of the combination embodiments described in Table 9 and numbered from 2313 to 2327 are shown, respectively, in the cells in the first row, which correspond to the numbered cell.

Table 10 provides 270 different combination embodiments of latanoprost, as shown in the first column labeled “Latanoprost % w/w”, and betaxolol as shown in the first row labeled “Betaxolol % w/w.” Specific concentrations of latanoprost and betaxolol for each of the combination embodiments described in Table 10 and numbered from 2583 to 2597 are shown, respectively, in the cells in the first row, which correspond to the numbered cell.

Table 11 provides 270 different combination embodiments of latanoprost, as shown in the first column labeled “Latanoprost % w/w”, and levobunolol as shown in the first row labeled “Levobunolol % w/w.” Specific concentrations of latanoprost and levobunolol for each of the combination embodiments described in Table 11 and numbered from 2853 to 2867 are shown, respectively, in the cells in the first row, which correspond to the numbered cell.

Table 12 provides 210 different combination embodiments of latanoprost, as shown in the first column labeled “Latanoprost % w/w”, and metipranolol as shown in the first row labeled “Metipranolol % w/w.” Specific concentrations of latanoprost and metipranolol for each of the combination embodiments described in Table 12 and numbered from 3123 to 3137 are shown, respectively, in the cells in the first row, which correspond to the numbered cell.

TABLE 1 Effective Amounts of Bimatoprost and Timolol Bimatoprost Timolol % w/w % w/w 0.0002 0.0004 0.0006 0.0008 0.0010 0.0020 0.0040 0.0060 0.0080 0.0100 0.001 1 20 39 58 77 96 115 134 153 172 0.002 2 21 40 59 78 97 116 135 154 173 0.003 3 22 41 60 79 98 117 136 155 174 0.004 4 23 42 61 80 99 118 137 156 175 0.005 5 24 43 62 81 100 119 138 157 176 0.006 6 25 44 63 82 101 120 139 158 177 0.007 7 26 45 64 83 102 121 140 159 178 0.008 8 27 46 65 84 103 122 141 160 179 0.009 9 28 47 66 85 104 123 142 161 180 0.010 10 29 48 67 86 105 124 143 162 181 0.020 11 30 49 68 87 106 125 144 163 182 0.030 12 31 50 69 88 107 126 145 164 183 0.040 13 32 51 70 89 108 127 146 165 184 0.050 14 33 52 71 90 109 128 147 166 185 0.060 15 34 53 72 91 110 129 148 167 186 0.070 16 35 54 73 92 111 130 149 168 187 0.080 17 36 55 74 93 112 131 150 169 188 0.090 18 37 56 75 94 113 132 151 170 189 0.100 19 38 57 76 95 114 133 152 171 190 Bimatoprost Timolol % w/w % w/w 0.0200 0.0400 0.0600 0.0800 0.10 0.15 0.20 0.25 0.001 191 210 229 248 267 286 305 324 0.002 192 211 230 249 268 287 306 325 0.003 193 212 231 250 269 288 307 326 0.004 194 213 232 251 270 289 308 327 0.005 195 214 233 252 271 290 309 328 0.006 196 215 234 253 272 291 310 329 0.007 197 216 235 254 273 292 311 330 0.008 198 217 236 255 274 293 312 331 0.009 199 218 237 256 275 294 313 332 0.010 200 219 238 257 276 295 314 333 0.020 201 220 239 258 277 296 315 334 0.030 202 221 240 259 278 297 316 335 0.040 203 222 241 260 279 298 317 336 0.050 204 223 242 261 280 299 318 337 0.060 205 224 243 262 281 300 319 338 0.070 206 225 244 263 282 301 320 339 0.080 207 226 245 264 283 302 321 340 0.090 208 227 246 265 284 303 322 341 0.100 209 228 247 266 285 304 323 342

TABLE 2 Effective Amounts of Bimatoprost and Betaxolol Bimatoprost Betaxolol % w/w % w/w 0.0002 0.0004 0.0006 0.0008 0.0010 0.0020 0.0040 0.0060 0.0080 0.001 343 362 381 400 419 438 457 476 495 0.002 344 363 382 401 420 439 458 477 496 0.003 345 364 383 402 421 440 459 478 497 0.004 346 365 384 403 422 441 460 479 498 0.005 347 366 385 404 423 442 461 480 499 0.006 348 367 386 405 424 443 462 481 500 0.007 349 368 387 406 425 444 463 482 501 0.008 350 369 388 407 426 445 464 483 502 0.009 351 370 389 408 427 446 465 484 503 0.010 352 371 390 409 428 447 466 485 504 0.020 353 372 391 410 429 448 467 486 505 0.030 354 373 392 411 430 449 468 487 506 0.040 355 374 393 412 431 450 469 488 507 0.050 356 375 394 413 432 451 470 489 508 0.060 357 376 395 414 433 452 471 490 509 0.070 358 377 396 415 434 453 472 491 510 0.080 359 378 397 416 435 454 473 492 511 0.090 360 379 398 417 436 455 474 493 512 0.100 361 380 399 418 437 456 475 494 513 Bimatoprost Betaxolol % w/w % w/w 0.0100 0.0200 0.0400 0.0600 0.0800 0.10 0.15 0.20 0.25 0.001 514 533 552 571 590 609 628 647 666 0.002 515 534 553 572 591 610 629 648 667 0.003 516 535 554 573 592 611 630 649 668 0.004 517 536 555 574 593 612 631 650 669 0.005 518 537 556 575 594 613 632 651 670 0.006 519 538 557 576 595 614 633 652 671 0.007 520 539 558 577 596 615 634 653 672 0.008 521 540 559 578 597 616 635 654 673 0.009 522 541 560 579 598 617 636 655 674 0.010 523 542 561 580 599 618 637 656 675 0.020 524 543 562 581 600 619 638 657 676 0.030 525 544 563 582 601 620 639 658 677 0.040 526 545 564 583 602 621 640 659 678 0.050 527 546 565 584 603 622 641 660 679 0.060 528 547 566 585 604 623 642 661 680 0.070 529 548 567 586 605 624 643 662 681 0.080 530 549 568 587 606 625 644 663 682 0.090 531 550 569 588 607 626 645 664 683 0.100 532 551 570 589 608 627 646 665 684

TABLE 3 Effective Amounts of Bimatoprost and Levobunolol Bimatoprost Levobunolol % w/w % w/w 0.0002 0.0004 0.0006 0.0008 0.0010 0.0020 0.0040 0.0060 0.0080 0.001 685 704 723 742 761 780 799 818 837 0.002 686 705 724 743 762 781 800 819 838 0.003 687 706 725 744 763 782 801 820 839 0.004 688 707 726 745 764 783 802 821 840 0.005 689 708 727 746 765 784 803 822 841 0.006 690 709 728 747 766 785 804 823 842 0.007 691 710 729 748 767 786 805 824 843 0.008 692 711 730 749 768 787 806 825 844 0.009 693 712 731 750 769 788 807 826 845 0.010 694 713 732 751 770 789 808 827 846 0.020 695 714 733 752 771 790 809 828 847 0.030 696 715 734 753 772 791 810 829 848 0.040 697 716 735 754 773 792 811 830 849 0.050 698 717 736 755 774 793 812 831 850 0.060 699 718 737 756 775 794 813 832 851 0.070 700 719 738 757 776 795 814 833 852 0.080 701 720 739 758 777 796 815 834 853 0.090 702 721 740 759 778 797 816 835 854 0.100 703 722 741 760 779 798 817 836 855 Bimatoprost Levobunolol % w/w % w/w 0.01 0.02 0.04 0.06 0.08 0.10 0.15 0.20 0.25 0.001 856 875 894 913 932 951 970 989 1008 0.002 857 876 895 914 933 952 971 990 1009 0.003 858 877 896 915 934 953 972 991 1010 0.004 859 878 897 916 935 954 973 992 1011 0.005 860 879 898 917 936 955 974 993 1012 0.006 861 880 899 918 937 956 975 994 1013 0.007 862 881 900 919 938 957 976 995 1014 0.008 863 882 901 920 939 958 977 996 1015 0.009 864 883 902 921 940 959 978 997 1016 0.010 865 884 903 922 941 960 979 998 1017 0.020 866 885 904 923 942 961 980 999 1018 0.030 867 886 905 924 943 962 981 1000 1019 0.040 868 887 906 925 944 963 982 1001 1020 0.050 869 888 907 926 945 964 983 1002 1021 0.060 870 889 908 927 946 965 984 1003 1022 0.070 871 890 909 928 947 966 985 1004 1023 0.080 872 891 910 929 948 967 986 1005 1024 0.090 873 892 911 930 949 968 987 1006 1025 0.100 874 893 912 931 950 969 988 1007 1026

TABLE 4 Effective Amounts of Bimatoprost and Metipranolol Bimatoprost Metipranolol % w/w % w/w 0.0030 0.0040 0.0060 0.0080 0.01 0.03 0.04 0.06 0.08 0.10 0.15 0.20 0.25 0.30 0.001 1027 1046 1065 1084 1103 1122 1141 1160 1179 1198 1217 1236 1255 1274 0.002 1028 1047 1066 1085 1104 1123 1142 1161 1180 1199 1218 1237 1256 1275 0.003 1029 1048 1067 1086 1105 1124 1143 1162 1181 1200 1219 1238 1257 1276 0.004 1030 1049 1068 1087 1106 1125 1144 1163 1182 1201 1220 1239 1258 1277 0.005 1031 1050 1069 1088 1107 1126 1145 1164 1183 1202 1221 1240 1259 1278 0.006 1032 1051 1070 1089 1108 1127 1146 1165 1184 1203 1222 1241 1260 1279 0.007 1033 1052 1071 1090 1109 1128 1147 1166 1185 1204 1223 1242 1261 1280 0.008 1034 1053 1072 1091 1110 1129 1148 1167 1186 1205 1224 1243 1262 1281 0.009 1035 1054 1073 1092 1111 1130 1149 1168 1187 1206 1225 1244 1263 1282 0.010 1036 1055 1074 1093 1112 1131 1150 1169 1188 1207 1226 1245 1264 1283 0.020 1037 1056 1075 1094 1113 1132 1151 1170 1189 1208 1227 1246 1265 1284 0.030 1038 1057 1076 1095 1114 1133 1152 1171 1190 1209 1228 1247 1266 1285 0.040 1039 1058 1077 1096 1115 1134 1153 1172 1191 1210 1229 1248 1267 1286 0.050 1040 1059 1078 1097 1116 1135 1154 1173 1192 1211 1230 1249 1268 1287 0.060 1041 1060 1079 1098 1117 1136 1155 1174 1193 1212 1231 1250 1269 1288 0.070 1042 1061 1080 1099 1118 1137 1156 1175 1194 1213 1232 1251 1270 1289 0.080 1043 1062 1081 1100 1119 1138 1157 1176 1195 1214 1233 1252 1271 1290 0.090 1044 1063 1082 1101 1120 1139 1158 1177 1196 1215 1234 1253 1272 1291 0.100 1045 1064 1083 1102 1121 1140 1159 1178 1197 1216 1235 1254 1273 1292

TABLE 5 Effective Amounts of Travoprost and Timolol Travoprost Timolol % w/w % w/w 0.0002 0.0004 0.0006 0.0008 0.0010 0.0020 0.0040 0.0060 0.0080 0.0002 1293 1308 1323 1338 1353 1368 1383 1398 1413 0.0004 1294 1309 1324 1339 1354 1369 1384 1399 1414 0.0006 1295 1310 1325 1340 1355 1370 1385 1400 1415 0.0008 1296 1311 1326 1341 1356 1371 1386 1401 1416 0.0010 1297 1312 1327 1342 1357 1372 1387 1402 1417 0.0020 1298 1313 1328 1343 1358 1373 1388 1403 1418 0.0040 1299 1314 1329 1344 1359 1374 1389 1404 1419 0.0060 1300 1315 1330 1345 1360 1375 1390 1405 1420 0.0080 1301 1316 1331 1346 1361 1376 1391 1406 1421 0.0100 1302 1317 1332 1347 1362 1377 1392 1407 1422 0.0200 1303 1318 1333 1348 1363 1378 1393 1408 1423 0.0400 1304 1319 1334 1349 1364 1379 1394 1409 1424 0.0600 1305 1320 1335 1350 1365 1380 1395 1410 1425 0.0800 1306 1321 1336 1351 1366 1381 1396 1411 1426 0.1000 1307 1322 1337 1352 1367 1382 1397 1412 1427 Travoprost Timolol % w/w % w/w 0.01 0.02 0.04 0.06 0.08 0.10 0.15 0.20 0.25 0.0002 1428 1443 1458 1473 1488 1503 1518 1533 1548 0.0004 1429 1444 1459 1474 1489 1504 1519 1534 1549 0.0006 1430 1445 1460 1475 1490 1505 1520 1535 1550 0.0008 1431 1446 1461 1476 1491 1506 1521 1536 1551 0.0010 1432 1447 1462 1477 1492 1507 1522 1537 1552 0.0020 1433 1448 1463 1478 1493 1508 1523 1538 1553 0.0040 1434 1449 1464 1479 1494 1509 1524 1539 1554 0.0060 1435 1450 1465 1480 1495 1510 1525 1540 1555 0.0080 1436 1451 1466 1481 1496 1511 1526 1541 1556 0.0100 1437 1452 1467 1482 1497 1512 1527 1542 1557 0.0200 1438 1453 1468 1483 1498 1513 1528 1543 1558 0.0400 1439 1454 1469 1484 1499 1514 1529 1544 1559 0.0600 1440 1455 1470 1485 1500 1515 1530 1545 1560 0.0800 1441 1456 1471 1486 1501 1516 1531 1546 1561 0.1000 1442 1457 1472 1487 1502 1517 1532 1547 1562

TABLE 6 Effective Amounts of Travoprost and Betaxolol Travoprost Betaxolol % w/w % w/w 0.0002 0.0004 0.0006 0.0008 0.0010 0.0020 0.0040 0.0060 0.0080 0.0002 1563 1578 1593 1608 1623 1638 1653 1668 1683 0.0004 1564 1579 1594 1609 1624 1639 1654 1669 1684 0.0006 1565 1580 1595 1610 1625 1640 1655 1670 1685 0.0008 1566 1581 1596 1611 1626 1641 1656 1671 1686 0.0010 1567 1582 1597 1612 1627 1642 1657 1672 1687 0.0020 1568 1583 1598 1613 1628 1643 1658 1673 1688 0.0040 1569 1584 1599 1614 1629 1644 1659 1674 1689 0.0060 1570 1585 1600 1615 1630 1645 1660 1675 1690 0.0080 1571 1586 1601 1616 1631 1646 1661 1676 1691 0.0100 1572 1587 1602 1617 1632 1647 1662 1677 1692 0.0200 1573 1588 1603 1618 1633 1648 1663 1678 1693 0.0400 1574 1589 1604 1619 1634 1649 1664 1679 1694 0.0600 1575 1590 1605 1620 1635 1650 1665 1680 1695 0.0800 1576 1591 1606 1621 1636 1651 1666 1681 1696 0.1000 1577 1592 1607 1622 1637 1652 1667 1682 1697 Travoprost Betaxolol % w/w % w/w 0.01 0.02 0.04 0.06 0.08 0.10 0.15 0.20 0.25 0.0002 1698 1713 1728 1743 1758 1773 1788 1803 1818 0.0004 1699 1714 1729 1744 1759 1774 1789 1804 1819 0.0006 1700 1715 1730 1745 1760 1775 1790 1805 1820 0.0008 1701 1716 1731 1746 1761 1776 1791 1806 1821 0.0010 1702 1717 1732 1747 1762 1777 1792 1807 1822 0.0020 1703 1718 1733 1748 1763 1778 1793 1808 1823 0.0040 1704 1719 1734 1749 1764 1779 1794 1809 1824 0.0060 1705 1720 1735 1750 1765 1780 1795 1810 1825 0.0080 1706 1721 1736 1751 1766 1781 1796 1811 1826 0.0100 1707 1722 1737 1752 1767 1782 1797 1812 1827 0.0200 1708 1723 1738 1753 1768 1783 1798 1813 1828 0.0400 1709 1724 1739 1754 1769 1784 1799 1814 1829 0.0600 1710 1725 1740 1755 1770 1785 1800 1815 1830 0.0800 1711 1726 1741 1756 1771 1786 1801 1816 1831 0.1000 1712 1727 1742 1757 1772 1787 1802 1817 1832

TABLE 7 Effective Amounts of Travoprost and Levobunolol Travoprost Levobunolol % w/w % w/w 0.0002 0.0004 0.0006 0.0008 0.0010 0.0020 0.0040 0.0060 0.0080 0.0002 1833 1848 1863 1878 1893 1908 1923 1938 1953 0.0004 1834 1849 1864 1879 1894 1909 1924 1939 1954 0.0006 1835 1850 1865 1880 1895 1910 1925 1940 1955 0.0008 1836 1851 1866 1881 1896 1911 1926 1941 1956 0.0010 1837 1852 1867 1882 1897 1912 1927 1942 1957 0.0020 1838 1853 1868 1883 1898 1913 1928 1943 1958 0.0040 1839 1854 1869 1884 1899 1914 1929 1944 1959 0.0060 1840 1855 1870 1885 1900 1915 1930 1945 1960 0.0080 1841 1856 1871 1886 1901 1916 1931 1946 1961 0.0100 1842 1857 1872 1887 1902 1917 1932 1947 1962 0.0200 1843 1858 1873 1888 1903 1918 1933 1948 1963 0.0400 1844 1859 1874 1889 1904 1919 1934 1949 1964 0.0600 1845 1860 1875 1890 1905 1920 1935 1950 1965 0.0800 1846 1861 1876 1891 1906 1921 1936 1951 1966 0.1000 1847 1862 1877 1892 1907 1922 1937 1952 1967 Travoprost Levobunolol % w/w % w/w 0.01 0.02 0.04 0.06 0.08 0.10 0.15 0.20 0.25 0.0002 1968 1983 1998 2013 2028 2043 2058 2073 2088 0.0004 1969 1984 1999 2014 2029 2044 2059 2074 2089 0.0006 1970 1985 2000 2015 2030 2045 2060 2075 2090 0.0008 1971 1986 2001 2016 2031 2046 2061 2076 2091 0.0010 1972 1987 2002 2017 2032 2047 2062 2077 2092 0.0020 1973 1988 2003 2018 2033 2048 2063 2078 2093 0.0040 1974 1989 2004 2019 2034 2049 2064 2079 2094 0.0060 1975 1990 2005 2020 2035 2050 2065 2080 2095 0.0080 1976 1991 2006 2021 2036 2051 2066 2081 2096 0.0100 1977 1992 2007 2022 2037 2052 2067 2082 2097 0.0200 1978 1993 2008 2023 2038 2053 2068 2083 2098 0.0400 1979 1994 2009 2024 2039 2054 2069 2084 2099 0.0600 1980 1995 2010 2025 2040 2055 2070 2085 2100 0.0800 1981 1996 2011 2026 2041 2056 2071 2086 2101 0.1000 1982 1997 2012 2027 2042 2057 2072 2087 2102

TABLE 8 Effective Amounts of Travoprost and Metipranolol Travoprost % Metipranolol % w/w w/w 0.0030 0.0040 0.0060 0.0080 0.01 0.03 0.04 0.06 0.08 0.10 0.15 0.20 0.25 0.30 0.0002 2103 2118 2133 2148 2163 2178 2193 2208 2223 2238 2253 2268 2283 2298 0.0004 2104 2119 2134 2149 2164 2179 2194 2209 2224 2239 2254 2269 2284 2299 0.0006 2105 2120 2135 2150 2165 2180 2195 2210 2225 2240 2255 2270 2285 2300 0.0008 2106 2121 2136 2151 2166 2181 2196 2211 2226 2241 2256 2271 2286 2301 0.0010 2107 2122 2137 2152 2167 2182 2197 2212 2227 2242 2257 2272 2287 2302 0.0020 2108 2123 2138 2153 2168 2183 2198 2213 2228 2243 2258 2273 2288 2303 0.0040 2109 2124 2139 2154 2169 2184 2199 2214 2229 2244 2259 2274 2289 2304 0.0060 2110 2125 2140 2155 2170 2185 2200 2215 2230 2245 2260 2275 2290 2305 0.0080 2111 2126 2141 2156 2171 2186 2201 2216 2231 2246 2261 2276 2291 2306 0.0100 2112 2127 2142 2157 2172 2187 2202 2217 2232 2247 2262 2277 2292 2307 0.0200 2113 2128 2143 2158 2173 2188 2203 2218 2233 2248 2263 2278 2293 2308 0.0400 2114 2129 2144 2159 2174 2189 2204 2219 2234 2249 2264 2279 2294 2309 0.0600 2115 2130 2145 2160 2175 2190 2205 2220 2235 2250 2265 2280 2295 2310 0.0800 2116 2131 2146 2161 2176 2191 2206 2221 2236 2251 2266 2281 2296 2311 0.1000 2117 2132 2147 2162 2177 2192 2207 2222 2237 2252 2267 2282 2297 2312

TABLE 9 Effective Amounts of Latanoprost and Timolol Latanoprost Timolol % w/w % w/w 0.0002 0.0004 0.0006 0.0008 0.0010 0.0020 0.0040 0.0060 0.0080 0.0003 2313 2328 2343 2358 2373 2388 2403 2418 2433 0.0005 2314 2329 2344 2359 2374 2389 2404 2419 2434 0.0007 2315 2330 2345 2360 2375 2390 2405 2420 2435 0.0009 2316 2331 2346 2361 2376 2391 2406 2421 2436 0.0010 2317 2332 2347 2362 2377 2392 2407 2422 2437 0.0030 2318 2333 2348 2363 2378 2393 2408 2423 2438 0.0050 2319 2334 2349 2364 2379 2394 2409 2424 2439 0.0070 2320 2335 2350 2365 2380 2395 2410 2425 2440 0.0090 2321 2336 2351 2366 2381 2396 2411 2426 2441 0.0100 2322 2337 2352 2367 2382 2397 2412 2427 2442 0.0300 2323 2338 2353 2368 2383 2398 2413 2428 2443 0.0500 2324 2339 2354 2369 2384 2399 2414 2429 2444 0.0700 2325 2340 2355 2370 2385 2400 2415 2430 2445 0.0900 2326 2341 2356 2371 2386 2401 2416 2431 2446 0.1000 2327 2342 2357 2372 2387 2402 2417 2432 2447 Latanoprost Timolol % w/w % w/w 0.01 0.02 0.04 0.06 0.08 0.10 0.15 0.20 0.25 0.0003 2448 2463 2478 2493 2508 2523 2538 2553 2568 0.0005 2449 2464 2479 2494 2509 2524 2539 2554 2569 0.0007 2450 2465 2480 2495 2510 2525 2540 2555 2570 0.0009 2451 2466 2481 2496 2511 2526 2541 2556 2571 0.0010 2452 2467 2482 2497 2512 2527 2542 2557 2572 0.0030 2453 2468 2483 2498 2513 2528 2543 2558 2573 0.0050 2454 2469 2484 2499 2514 2529 2544 2559 2574 0.0070 2455 2470 2485 2500 2515 2530 2545 2560 2575 0.0090 2456 2471 2486 2501 2516 2531 2546 2561 2576 0.0100 2457 2472 2487 2502 2517 2532 2547 2562 2577 0.0300 2458 2473 2488 2503 2518 2533 2548 2563 2578 0.0500 2459 2474 2489 2504 2519 2534 2549 2564 2579 0.0700 2460 2475 2490 2505 2520 2535 2550 2565 2580 0.0900 2461 2476 2491 2506 2521 2536 2551 2566 2581 0.1000 2462 2477 2492 2507 2522 2537 2552 2567 2582

TABLE 10 Effective Amounts of Latanoprost and Betaxolol Latanoprost Betaxolol % w/w % w/w 0.0002 0.0004 0.0006 0.0008 0.0010 0.0020 0.0040 0.0060 0.0080 0.0003 2583 2598 2613 2628 2643 2658 2673 2688 2703 0.0005 2584 2599 2614 2629 2644 2659 2674 2689 2704 0.0007 2585 2600 2615 2630 2645 2660 2675 2690 2705 0.0009 2586 2601 2616 2631 2646 2661 2676 2691 2706 0.0010 2587 2602 2617 2632 2647 2662 2677 2692 2707 0.0030 2588 2603 2618 2633 2648 2663 2678 2693 2708 0.0050 2589 2604 2619 2634 2649 2664 2679 2694 2709 0.0070 2590 2605 2620 2635 2650 2665 2680 2695 2710 0.0090 2591 2606 2621 2636 2651 2666 2681 2696 2711 0.0100 2592 2607 2622 2637 2652 2667 2682 2697 2712 0.0300 2593 2608 2623 2638 2653 2668 2683 2698 2713 0.0500 2594 2609 2624 2639 2654 2669 2684 2699 2714 0.0700 2595 2610 2625 2640 2655 2670 2685 2700 2715 0.0900 2596 2611 2626 2641 2656 2671 2686 2701 2716 0.1000 2597 2612 2627 2642 2657 2672 2687 2702 2717 Latanoprost Betaxolol % w/w % w/w 0.01 0.02 0.04 0.06 0.08 0.10 0.15 0.20 0.25 0.0003 2718 2733 2748 2763 2778 2793 2808 2823 2838 0.0005 2719 2734 2749 2764 2779 2794 2809 2824 2839 0.0007 2720 2735 2750 2765 2780 2795 2810 2825 2840 0.0009 2721 2736 2751 2766 2781 2796 2811 2826 2841 0.0010 2722 2737 2752 2767 2782 2797 2812 2827 2842 0.0030 2723 2738 2753 2768 2783 2798 2813 2828 2843 0.0050 2724 2739 2754 2769 2784 2799 2814 2829 2844 0.0070 2725 2740 2755 2770 2785 2800 2815 2830 2845 0.0090 2726 2741 2756 2771 2786 2801 2816 2831 2846 0.0100 2727 2742 2757 2772 2787 2802 2817 2832 2847 0.0300 2728 2743 2758 2773 2788 2803 2818 2833 2848 0.0500 2729 2744 2759 2774 2789 2804 2819 2834 2849 0.0700 2730 2745 2760 2775 2790 2805 2820 2835 2850 0.0900 2731 2746 2761 2776 2791 2806 2821 2836 2851 0.1000 2732 2747 2762 2777 2792 2807 2822 2837 2852

TABLE 11 Effective Amounts of Latanoprost and Levobunolol Latanoprost Levobunolol % w/w % w/w 0.0002 0.0004 0.0006 0.0008 0.0010 0.0020 0.0040 0.0060 0.0080 0.0003 2853 2868 2883 2898 2913 2928 2943 2958 2973 0.0005 2854 2869 2884 2899 2914 2929 2944 2959 2974 0.0007 2855 2870 2885 2900 2915 2930 2945 2960 2975 0.0009 2856 2871 2886 2901 2916 2931 2946 2961 2976 0.0010 2857 2872 2887 2902 2917 2932 2947 2962 2977 0.0030 2858 2873 2888 2903 2918 2933 2948 2963 2978 0.0050 2859 2874 2889 2904 2919 2934 2949 2964 2979 0.0070 2860 2875 2890 2905 2920 2935 2950 2965 2980 0.0090 2861 2876 2891 2906 2921 2936 2951 2966 2981 0.0100 2862 2877 2892 2907 2922 2937 2952 2967 2982 0.0300 2863 2878 2893 2908 2923 2938 2953 2968 2983 0.0500 2864 2879 2894 2909 2924 2939 2954 2969 2984 0.0700 2865 2880 2895 2910 2925 2940 2955 2970 2985 0.0900 2866 2881 2896 2911 2926 2941 2956 2971 2986 0.1000 2867 2882 2897 2912 2927 2942 2957 2972 2987 Latanoprost Levobunolol % w/w % w/w 0.01 0.02 0.04 0.06 0.08 0.10 0.15 0.20 0.25 0.0003 2988 3003 3018 3033 3048 3063 3078 3093 3108 0.0005 2989 3004 3019 3034 3049 3064 3079 3094 3109 0.0007 2990 3005 3020 3035 3050 3065 3080 3095 3110 0.0009 2991 3006 3021 3036 3051 3066 3081 3096 3111 0.0010 2992 3007 3022 3037 3052 3067 3082 3097 3112 0.0030 2993 3008 3023 3038 3053 3068 3083 3098 3113 0.0050 2994 3009 3024 3039 3054 3069 3084 3099 3114 0.0070 2995 3010 3025 3040 3055 3070 3085 3100 3115 0.0090 2996 3011 3026 3041 3056 3071 3086 3101 3116 0.0100 2997 3012 3027 3042 3057 3072 3087 3102 3117 0.0300 2998 3013 3028 3043 3058 3073 3088 3103 3118 0.0500 2999 3014 3029 3044 3059 3074 3089 3104 3119 0.0700 3000 3015 3030 3045 3060 3075 3090 3105 3120 0.0900 3001 3016 3031 3046 3061 3076 3091 3106 3121 0.1000 3002 3017 3032 3047 3062 3077 3092 3107 3122

TABLE 12 Effective Amounts of Latanoprost and Metipranolol Latanoprost Metipranolol % w/w % w/w 0.0030 0.0040 0.0060 0.0080 0.01 0.03 0.04 0.06 0.08 0.10 0.15 0.20 0.25 0.30 0.0003 3123 3138 3153 3168 3183 3198 3213 3228 3243 3258 3273 3288 3303 3318 0.0005 3124 3139 3154 3169 3184 3199 3214 3229 3244 3259 3274 3289 3304 3319 0.0007 3125 3140 3155 3170 3185 3200 3215 3230 3245 3260 3275 3290 3305 3320 0.0009 3126 3141 3156 3171 3186 3201 3216 3231 3246 3261 3276 3291 3306 3321 0.0010 3127 3142 3157 3172 3187 3202 3217 3232 3247 3262 3277 3292 3307 3322 0.0030 3128 3143 3158 3173 3188 3203 3218 3233 3248 3263 3278 3293 3308 3323 0.0050 3129 3144 3159 3174 3189 3204 3219 3234 3249 3264 3279 3294 3309 3324 0.0070 3130 3145 3160 3175 3190 3205 3220 3235 3250 3265 3280 3295 3310 3325 0.0090 3131 3146 3161 3176 3191 3206 3221 3236 3251 3266 3281 3296 3311 3326 0.0100 3132 3147 3162 3177 3192 3207 3222 3237 3252 3267 3282 3297 3312 3327 0.0300 3133 3148 3163 3178 3193 3208 3223 3238 3253 3268 3283 3298 3313 3328 0.0500 3134 3149 3164 3179 3194 3209 3224 3239 3254 3269 3284 3299 3314 3329 0.0700 3135 3150 3165 3180 3195 3210 3225 3240 3255 3270 3285 3300 3315 3330 0.0900 3136 3151 3166 3181 3196 3211 3226 3241 3256 3271 3286 3301 3316 3331 0.1000 3137 3152 3167 3182 3197 3212 3227 3242 3257 3272 3287 3302 3317 3332

II. METHODS OF TREATMENT

Methods of treating an ophthalmic disease are provided, including methods of treating glaucoma. In particular, the methods according to the embodiments of the present invention are useful in decreasing IOP without causing conjunctival hyperemia. Some embodiments of the methods provided herein include applying an ophthalmic formulation described herein to the region on or around the eye, which can treat ophthalmic diseases by sustained administration of an effective amount of an active pharmaceutical ingredient (e.g., a prostaglandin agent) and a sub-therapeutic amount of an active pharmaceutical ingredient (e.g., a vasoconstrictor agent), as described herein, to the ophthalmic tissue (i.e. conjunctiva, lacrimal tissue or cornea). The methods provided herein further include administering any appropriate ophthalmically acceptable excipient.

In another aspect, a method of reducing increased intraocular pressure (IOP) in a subject in need thereof is provided. The method includes administering to the subject a therapeutically effective amount of an ophthalmic pharmaceutical formulation including a prostaglandin agent and a vasoconstrictor agent as provided herein. In some embodiments, the subject is in need of treatment for glaucoma. In other embodiments, the subject displays conjunctival hyperemia.

In some embodiments, the prostaglandin agent is present in a therapeutically effective amount and the vasoconstrictor agent is present in a sub-therapeutic amount. In other embodiments, the prostaglandin agent is bimatoprost and the vasoconstrictor agent is timolol. In some embodiments, the ophthalmic pharmaceutical formulation further includes a buffering agent, a tonicity agent, a salt, a thickening agent and a preservative. In other embodiments, the ophthalmic pharmaceutical formulation consists essentially of bimatoprost, timolol, a buffering agent, a tonicity agent, a salt, a thickening agent and a preservative. In some embodiments, the bimatoprost is present in a therapeutically effective amount and the timolol is present in a sub-therapeutic amount.

III. EXAMPLES

Embodiments of the present invention are further illustrated by the following examples, which are not to be construed in any way as imposing limitations upon the scope thereof. On the contrary, it is to be clearly understood that resort may be made to various other embodiments, modifications and equivalents, which, after reading the description provided herein, may suggest themselves to those skilled in the art without departing from the spirit of the invention.

Bimatoprost 0.03% (Lumigan®), given once daily, is a highly efficacious intraocular pressure (IOP) lowering drug (Chen J et al., Optometry Pract 2002; 3:95-102; Cohen J S et al., Surv Ophthalmol 2004; 49:S45-S52; Christiansen G A et al., Ophthalmology 2004; 111:1658-1662; DuBiner H et al., Surv Ophthalmol 2001; 45(Suppl 4):S353-S360; Eisenberg D L, Toris C B, Camras C B, Surv Ophthalmol 2002; 47:S105-S115; Gandolfi S A, Cimino L., Ophthalmology 2003; 110:609-614; Higginbotham E J, Schuman J S, Goldberg I, et al., Arch Ophthalmol 2002; 120:1286-1293; Noecker R S et al., Am J Ophthalmol 2003; 135:55-63; Parrish R K, Palmberg P, Sheu W-P., Am J Ophthalmol 2003; 135:688-703; Williams R D., Adv Ther 2002; 19:275-281). It has a very high systemic safety margin in studies conducted in laboratory animals (Woodward D F, Phelps R L, Krauss A H-P, et al., Cardiovasc Drug Rev 2004; 22:103-120). The most common ocular side effect associated with bimatoprost in humans is conjunctival hyperemia. This effect is usually mild and diminishes over time (Abelson M B et al., Adv Ther 2003; 20:1-13; Cohen J S et al., Surv Ophthalmol 2004; 49:S45-S52; DuBiner H et al., Surv Ophthalmol 2001; 45(Suppl 4):S353-S360; Eisenberg D L, Toris C B, Camras C B, Surv Ophthalmol 2002; 47:S105-S115; Higginbotham E J, Schuman J S, Goldberg I, et al., Arch Ophthalmol 2002; 120:1286-1293; Noecker R S et al., Am J Ophthalmol 2003; 135:55-63; Parrish R K, Palmberg P, Sheu W-P., Am J Ophthalmol 2003; 135:688-703; Stewart W C et al., Am J Ophthalmol 2003; 135:314-320).

Latanoprost (Xalatan®), a prostaglandin FP receptor agonist prodrug, is a well-established IOP lowering medication that has been used as a comparator for ocular hypotensive and conjunctival hyperemia effects (DuBiner H et al., Surv Ophthalmol 2001; 45(Suppl 4):S353-S360; Eisenberg D L, Toris C B, Camras C B, Surv Ophthalmol 2002; 47:S105-S115; Gandolfi S A, Cimino L., Ophthalmology 2003; 110:609-614; Noecker R S et al., Am J Ophthalmol 2003; 135:55-63; Parrish R K, Palmberg P, Sheu W-P., Am J Ophthalmol 2003; 135:688-703; Stewart W C et al., Am J Ophthalmol 2003; 135:314-320). Bimatoprost and latanoprost exhibit different pharmacological profiles and stimulate different receptor populations, bimatoprost-sensitive and prostanoid FP receptors, respectively (Chen J et al., Br J Pharmacol 2005; 144:493-501; Spada C S, Krauss A H-P, Woodward D F, et al., Exp Eye Res 2005; 80:135-145; Woodward D F, Krauss A H-P, Chen J, et al., Surv. Ophthalmol 2001; 45:S337-S345; Woodward D F, Krauss A H-P, Chen J, et al., J Pharmacol Exp Ther 2003; 305:772-785). Nevertheless, bimatoprost and prostanoid FP agonists have similarities with respect to endothelium-dependent vasodilatation in blood vessels (Astin M, Stjernschantz J, Selén G., Exp Eye Res 1994; 59:401-408; Astin M, Stjernschantz J., Eur J Pharmacol 1997; 340:195-201; Astin M, Stjernschantz J., Curr Eye Res 1997; 16:886-890; Astin M., J Ocul Pharmacol 1998; 14:119-128; Chen J. et al., Br J Pharmacol 1995; 116:3035-3041; Chen J, Woodward D F. Adv Exp Med Biol 2002; 507:331-336; Chen J et al., Br J Pharmacol 2005; 144:493-501; Stewart W C et al., Am J Ophthalmol 2003; 135:314-320) and stimulation of intracellular calcium signaling, but in different cell populations of the cat iris sphincter (Spada C S, Krauss A H-P, Woodward D F, et al., Exp Eye Res 2005; 80:135-145).

Vasorelaxation produced by the stimulation of endothelial muscarinic receptors and mediated by an endothelium-derived substance was originally discovered by Furchgott and Zawadzki (Furchgott R F, Zawadzki J V., Nature 1980; 288:373-376). This substance was identified as nitric oxide (NO) by numerous studies in the mid-1980s. In endothelial cells, increases in intracellular calcium activate endothelial nitric oxide synthase (eNOS) and lead to the generation of nitric oxide, an important regulator of ocular blood flow (Albrecht E W et al., J Pathol 2003; 1999:8-17; Koss M C., Eur J Pharmacol 1999; 374:161-174; Schmetterer L, Polak K, Prog Retin Eye Res. 2001; 20:823-847). All isoforms of NOS have been identified in eyes, including ocular surface cells (Kim J C et al., J Korean Med Sci 2002; 17:389-394; Schmetterer L, Polak K, Prog Retin Eye Res. 2001; 20:823-847). The endothelial NOS isoform, also referred to as NOS-3, has often been reported to have a protective role in a number of disease states and inflammatory processes (Albrecht E W et al., J Pathol 2003; 1999:8-17), but under certain conditions eNOS may also contribute to inflammatory responses (Cirino G, Fiorucci S, Sessa W C., Trends Pharmacol Sci 2003; 24:91-95).

Studies in patients have addressed the long-term safety of bimatoprost and the time course of bimatoprost-induced conjunctival hyperemia (Abelson M B et al., Adv Ther 2003; 20:1-13; Cohen J S et al., Surv Ophthalmol 2004; 49:S45-S52; Higginbotham E J, Schuman J S, Goldberg I, et al., Arch Ophthalmol 2002; 120:1286-1293). More recent studies investigated the inflammatory potential of bimatoprost using human conjunctival biopsies and cells (Guenoun J-M et al., Invest Ophthalmol Vis Sci 2005; 46:2444-2450; Leal B C et al., Am J Ophthalmol 2004; 138:310-313; Mroz M, Abelson M B et al., Invest Ophthalmol Vis Sci 2003; 44:ARVOE-Abstract 4417). However, information from humans is limited, so animal models have been used to investigate safety issues, the pharmacological mechanism of hyperemia, and the possible involvement of ocular surface inflammation. The ocular surface safety of topical bimatoprost treatment in animals was established in multiple-dose studies performed for the development of bimatoprost (Lumigan (Bimatoprost) Ophthalmic Solution. Pharmacology Review of New Drug Application 21-275. FDA/Center for Drug Evaluation and Research. 2001; Part 1 and Part 2:1-107. Available online at http://www.fda.gov/cder/foi/nda/2001/21275_Lumigan.htm). Other preclinical studies showed that hyperemic effects of bimatoprost on the vasculature occur by a non-inflammatory, nitric oxide-mediated vasodilatation.

Clinical Hyperemia

A month-long, multicenter, open-label study evaluated the onset and progression of conjunctival hyperemia associated with bimatoprost 0.03% once daily during 6 office visits (Abelson M B et al., Adv Ther 2003; 20:1-13). The 39 patients enrolled in the study had bilateral open-angle glaucoma or ocular hypertension and had not been treated previously with bimatoprost. An overall mean hyperemia score was calculated for each visit by averaging three vessel-bed scores obtained by slit-lamp biomicroscopy. The frequency and severity of hyperemia peaked approximately 1 day after the first instillation of bimatoprost and decreased consistently throughout the study, returning to near baseline levels by day 28 (Abelson M B et al., Adv Ther 2003; 20:1-13; FIG. 1). The hyperemia was considered not clinically significant.

The long-term safety of bimatoprost was compared to that of timolol in patients with glaucoma or ocular hypertension (Higginbotham E J, Schuman J S, Goldberg I, et al., Arch Ophthalmol 2002; 120:1286-1293). In two identical, multicenter, randomized, double-blind, 1-year clinical trials, patients were treated with bimatoprost 0.03% once daily (n=474), bimatoprost 0.03% twice daily (n=483), or timolol maleate 0.5% twice daily (n=241). Laser-flare photometry measurements (a common measure of intraocular inflammation) were taken in a subset of 310 patients (124 in the bimatoprost q.d. group, 123 in the bimatoprost b.i.d. group, and 63 in the timolol group). There were no significant differences among the treatment groups in mean laser-flare photometry readings or in mean changes from baseline. In addition, no increase in flare readings was observed in those patients who developed conjunctival hyperemia during the trial. The results indicate that bimatoprost-induced conjunctival hyperemia is not associated with intraocular inflammation in patients treated for one year. Bimatoprost was also shown to be safe and well-tolerated in the study extension to 2 years (Cohen J S et al., Surv Ophthalmol 2004; 49:S45-S52).

In a prospective interventional study, histological signs of inflammation were evaluated in conjunctival biopsies from patients with bimatoprost-associated conjunctival hyperemia who were scheduled to undergo cataract surgery (Leal B C et al., Am J Ophthalmol 2004; 138:310-313; FIG. 2). Patients with primary open-angle glaucoma were treated with bimatoprost 0.03% q.d. for 2 to 4 weeks. Nine of 13 eyes treated with bimatoprost developed conjunctival hyperemia and only those eyes were included in the study. The control eyes (n=6) were untreated and had no history of ocular disease other than cataracts. Results showed that signs of inflammation were no more frequent in conjunctival specimens from untreated control patients than in those from bimatoprost-treated patients with trace to moderate hyperemia. Vascular congestion was observed in 83% (5/6) of eyes in the control group and 78% (7/9) of eyes in the bimatoprost treatment group. Signs of inflammatory cell margination or infiltration were present in 33% (2/6) of control eyes compared with 22% (2/9) of bimatoprost-treated eyes and were not related to treatment. The findings of this study demonstrated that bimatoprost-related hyperemia was not associated with histological evidence of inflammation. In another study, bulbar conjunctival biopsies taken at day 7 and impression cytology specimens from patients treated with bimatoprost 0.03% q.d. for 60 days also showed no evidence of inflammation (Mroz M, Abelson M B et al., Invest Ophthalmol Vis Sci 2003; 44:ARVOE-Abstract 4417).

An in vitro study of the expression of various inflammation-associated markers in human cultured conjunctiva-derived epithelial cells was conducted for bimatoprost, along with the prostaglandin FP agonists: latanoprost and travoprost (Guenoun J-M et al., Invest Ophthalmol Vis Sci 2005; 46:2444-2450). None of the drugs appeared to induce direct stimulation of inflammatory pathways involving adhesion molecules or class II antigens. The toxicity observed was mild and primarily related to the concentration of the preservative benzalkonium chloride (BAK). These results are consistent with those obtained from the in-life studies and suggest that conjunctival hyperemia is most likely not an inflammatory response to bimatoprost. Furthermore, it appears too early after onset of treatment to be the inflammatory consequence of long-term treatment.

Pharmacology in Animal Models

Nitric oxide is a predominant second messenger, with a possible compensatory role for potassium channels, in prostaglandin F2a (PGF2a)-induced relaxation of rabbit endothelium-intact jugular veins (Chen J. et al., Br J Pharmacol 1995; 116:3035-3041). The vasorelaxation produced by PGF2a and latanoprost free acid in rabbit submental veins was also found to be mediated by NO and, in addition, by sensory nerves (Astin M, Stjernschantz J., Eur J Pharmacol 1997; 340:195-201). In rabbits, NO and sensory nerves were reported to have roles in PGF2a-induced ocular hyperemia as determined by NOS inhibition and sensory denervation (Astin M, Stjernschantz J, Selén G., Exp Eye Res 1994; 59:401-408; Astin M, Stjernschantz J., Curr Eye Res 1997; 16:886-890). The effects of PGF2a and its analogs, which did not include latanoprost, on ocular surface hyperemia (OSH) in dog eyes correlated with the vasorelaxation in endothelium-intact rabbit precontracted jugular veins (Chen J, Woodward D F. Adv Exp Med Biol 2002; 507:331-336). Taken together, these studies suggest that the pharmacological mechanism of conjunctival hyperemia elicited by bimatoprost and latanoprost may be elucidated by comparing their responses in the isolated jugular vein and conscious dog eyes and using NOS inhibition to determine NO involvement in vasorelaxation and OSH. A methodological difference between these in vitro tissue studies and the in vivo and human in-life studies is that a cyclooxygenase inhibitor such as indomethacin is generally used in the isolated tissue bioassay experiments. Thus, the possibility that products of arachidonic acid cyclooxygenation could be generated de novo and contribute to the vasorelaxation was examined in the rabbit jugular vein preparation.

Effects of Bimatoprost and Latanoprost Free Acid on Rabbit Isolated Jugular Veins

The pharmacological mechanism of ocular surface hyperemia elicited by bimatoprost and latanoprost was investigated using the rabbit jugular vein preparation as a quantitative in vitro model (Chen J. et al., Br J Pharmacol 1995; 116:3035-3041). In these studies, tissues were suspended in jacketed organ baths containing Krebs buffer with 1 μM indomethacin (endothelium-intact and -denuded) or in its absence (endothelium-intact) and precontracted with 3 μM histamine. Vasorelaxant and contractile activity were determined as a percentage (%) of the control tone elicited by histamine. Statistical comparisons for the vasorelaxant activity consisted of testing for significance of difference at each of the concentrations tested using the Student'-s t-test for unpaired samples (indomethacin vs no indomethacin) and paired samples (L-NAME vs D-NAME). Differences were considered statistically significant for P-values≦0.05.

Bimatoprost and latanoprost free acid produced endothelium-dependent vasorelaxant effects that are consistent with and extend previously reported data (Chen J et al., Invest Ophthalmol Vis Sci 2004; 45:ARVO E-Abstract 2609; Lumigan (Bimatoprost) Ophthalmic Solution. Pharmacology Review of New Drug Application 21-275. FDA/Center for Drug Evaluation and Research. 2001; Part 1 and Part 2:1-107. Available online at http://www.fda.gov/cder/foi/nda/2001/21275_Lumigan.htm). Bimatoprost produced a weak vasorelaxant response (EC₅₀=3,981 nM) at high concentrations in endothelium-intact jugular veins and was inactive in the endothelium-denuded preparation (Chen J et al., Br J Pharmacol 2005; 144:493-501; FIG. 3A). This response profile is consistent with a wide separation between its IOP lowering and ocular surface hyperemia effects. Bimatoprost produced vasorelaxant responses at the 10⁻⁶ M to 10⁻⁴ M concentrations (FIGS. 3A, 5A), which encompassed concentrations (10⁻⁶-10⁻⁵ molar equivalent) found in non-human primate ocular surface tissues after single or multiple topical bimatoprost dosing (Woodward D F, Krauss A H-P, Chen J, et al., J Pharmacol Exp Ther 2003; 305:772-785; Woodward D F, Phelps R L, Krauss A H-P, et al., Cardiovasc Drug Rev 2004; 22:103-120). The weak vasorelaxant response to bimatoprost in the rabbit jugular vein was predictive for the findings of mean mild conjunctival hyperemia in human subjects, although the hyperemia severity may vary according to the tissue concentrations achieved.

Latanoprost free acid produced complex concentration-response curves of maximal vasorelaxation at 10⁻⁷ M and a reversal of the relaxant effects at higher concentrations of 10⁻⁶ M and 10⁻⁵ M in the endothelium-intact preparation and only contractions at the 10⁻⁵ M concentration in endothelium-denuded veins (Chen J et al., Invest Ophthalmol Vis Sci 2004; 45:ARVO E-Abstract 2609; Lumigan (Bimatoprost) Ophthalmic Solution. Pharmacology Review of New Drug Application 21-275. FDA/Center for Drug Evaluation and Research. 2001; Part 1 and Part 2:1-107. Available online at http://www.fda.gov/cder/foi/nda/2001/21275 Lumigan.htm; FIG. 3B). The response to latanoprost free acid in the jugular veins was interesting in that it produced vasorelaxation at the lower concentrations tested and this response reversed at higher concentrations. This effect, particularly the reversal at high concentrations, may contribute to a decreased ability of latanoprost to elicit ocular surface hyperemia compared to bimatoprost and correlates with its mild conjunctival hyperemia response in humans (Eisenberg D L, Toris C B, Camras C B, Surv Ophthalmol 2002; 47:S105-S115; Noecker R S et al., Am J Ophthalmol 2003; 135:55-63; Parrish R K, Palmberg P, Sheu W-P., Am J Ophthalmol 2003; 135:688-703; Stewart W C et al., Am J Ophthalmol 2003; 135:314-320). The vasoconstrictor effects of latanoprost free acid in both the endothelium-intact and -denuded veins suggested the possible involvement of contractile prostanoid TP receptors. However, TP stimulation does not explain reversal of the vasorelaxant response to latanoprost free acid at pharmacological concentrations up to 10⁻⁶ M, since the TP antagonist SQ 29548 used in these studies is highly effective yet did not block the reversal of the vasorelaxant response. Moreover, latanoprost free acid did not contract the endothelium-denuded preparation over the concentration range of 10⁻¹⁰ to 10⁻⁶ M. Therefore, reversal of the vasorelaxant response to latanoprost free acid in the rabbit jugular vein may involve an endothelial FP receptor or even perhaps a previously unrecognized receptor that causes endothelium-induced vasoconstriction. The increased variability in latanoprost free acid responses at the higher concentrations was likely due to the opposing vasorelaxant and vasoconstrictor effects.

These different activity profiles for latanoprost free acid and bimatoprost in the rabbit jugular vein provide further pharmacological evidence that these agents are recognized by different receptor populations. Latanoprost free acid is a well-known potent and selective prostanoid FP receptor agonist, while bimatoprost is a putative prostamide receptor agonist. Studies using isolated tissue preparations and DNA synthesis in mouse cultured fibroblasts have shown that species-, tissue-, or preparation-related factors, partial agonism, and metabolism all do not provide acceptable explanations of the different activity profiles of bimatoprost and prostanoid FP receptor agonists (Chen J et al., Br J Pharmacol 2005; 144:493-501). The results from the rabbit jugular vein model add support to the contention that bimatoprost is a prostamide and produces its effects by stimulating bimatoprost-sensitive receptors as opposed to prostanoid FP receptors.

Indomethacin is a cyclooxygenase inhibitor that is routinely used in prostanoid receptor assays (Chen J et al., Current protocols in pharmacology. New York: John Wiley & Sons, Inc., 2001; 4.18.1-4.18.41). Studies of intact and viable isolated tissues, such as the rabbit jejunum (Ferreira S H, Herman A G, Vane J R., Br J Pharmacol 1976; 56:469-477) and human bronchial muscle (Hage-Legrand I, Cerrina J, Raffestin B et al., J Pharmacol Exp Ther 1986; 239:536-541), found the basal output of prostaglandins to be 8-23 pg/mg of tissue at baseline or over 30 min collection periods. In the presence of 1.7 and 2.79 μM indomethacin, the amounts of prostaglandins generated in isolated tissues become negligible (Botting J H, Salzmann R., Br J Pharmacol 1974; 50:119-124; Haye-Legrand I, Cerrina J, Raffestin B et al., J Pharmacol Exp Ther 1986; 239:536-541). The 1 μM concentration of indomethacin in the tissue bath, in our experience, is sufficient to prevent biosynthesis of prostanoids within isolated vascular tissue preparations (Alster P, Wennmalm Å., Eur J Pharmacol 1983; 86:441-446; Chen J et al., Current protocols in pharmacology. New York: John Wiley & Sons, Inc., 2001; 4.18.1-4.18.41). At substantially higher concentrations, indomethacin has been reported to lose selectivity for prostanoid biosynthesis inhibition (Aboulafia J et al., Br J Pharmacol 1976; 58:223-228; Goodfriend T L, Simpson R U., Br J Pharmacol 1981; 72:247-255; Northover B J, Br J Pharmacol 1971; 41:540-551; Sawdy R et al., Br J Pharmacol 1998; 125:1212-1217). The rabbit jugular vein studies were conducted under experimental conditions of intact isolated tissues continually bathed in buffer containing 1 μM indomethacin. Results of these studies are consistent with and extend previously reported findings (Lumigan (Bimatoprost) Ophthalmic Solution. Pharmacology Review of New Drug Application 21-275. FDA/Center for Drug Evaluation and Research. 2001; Part 1 and Part 2:1-107. Available online at http://www.fda.gov/cder/foi/nda/2001/21275_Lumigan.htm). The contractile response to histamine in all of the tissues examined without indomethacin was superimposed with spontaneous spike activity, indicating a contribution of prostaglandin production to the contractions. In the presence of indomethacin, the histamine-induced contractions were well-maintained, stable, and showed minimal spontaneous activity. Endothelium-intact tissues incubated with and without 1 μM indomethacin showed no statistically significant differences in effects between the means and at each of the concentrations tested for bimatoprost and latanoprost free acid (Lumigan (Bimatoprost) Ophthalmic Solution. Pharmacology Review of New Drug Application 21-275. FDA/Center for Drug Evaluation and Research. 2001; Part 1 and Part 2:1-107. Available online at http://www.fda.gov/cder/foi/nda/2001/21275 Lumigan.htm; FIG. 4). These findings suggest that responses to these agents in the rabbit isolated jugular vein are mediated by endothelial located receptors and not by de novo biosynthesis of prostaglandins. Consequently, these in vitro responses can be compared with those observed in the in vivo and in-life studies.

The involvement of nitric oxide in bimatoprost- and latanoprost free acid-induced relaxation of the rabbit jugular vein was determined using L-NAME (L-N^(G)-nitroarginine methyl ester), a potent enantiomerically specific competitive inhibitor of NOS in cell types that include vascular endothelial cells (Koss M C., Eur J Pharmacol 1999; 374:161-174; Rees D D et al., Br J Pharmacol 1990; 101:746-752), and its inactive isomer D-NAME. In the endothelium-intact histamine precontracted tissues, 100 μM L-NAME significantly inhibited the vasorelaxant responses to bimatoprost and latanoprost free acid, compared to their respective responses in the 100 μM D-NAME control tissues, P≦0.05, paired t-test (FIG. 5). This result indicates that NO is an important contributor to vasorelaxation produced by bimatoprost and latanoprost free acid in the rabbit jugular vein and is consistent with previous findings for PGF_(2a). (Chen J. et al., Br J Pharmacol 1995; 116:3035-3041). L-NAME at 100 μM was less effective in inhibiting the responses to PGF_(2a). (Chen J. et al., Br J Pharmacol 1995; 116:3035-3041) compared to bimatoprost and latanoprost free acid, which may reflect the selectivity of these agents for their respective receptors.

Effects of Nitric Oxide Synthase Inhibition on Conjunctival Hyperemia in Dog Eye

The ocular surface hyperemic effects of bimatoprost, latanoprost (isopropyl ester), or prostaglandin E₂ (PGE₂) were determined in eyes of conscious dogs treated with topical L-NAME or D-NAME. The dog is suitable for OSH studies since it responds with mild conjunctival hyperemia to bimatoprost and latanoprost, which is consistent with the hyperemic responses observed in humans. The rabbit eye is less predictive for conjunctival hyperemia since latanoprost has no significant acute effects on blood flow in the conjunctiva at a topical dose of 10 μg (0.03%, based on a 30 μl volume) (Astin M, Stjernschantz J, Selén G., Exp Eye Res 1994; 59:401-408; Stjernschantz J et al., Prog Retin Eye Res 2000; 19:459-496). In vivo experiments consisted of visually grading ocular surface hyperemia (OSH) in conscious Beagle dogs (males or females). All test articles were administered in a masked fashion. The test compound was applied bilaterally as a single drop at time (t)=0 in the one day study. L-NAME 1% (w/v) was topically applied to one eye, while its inactive isomer D-NAME 1% (w/v) was given to the contralateral eye, at 90, 60, 30, 5 min pre-dose, and 1, 2, 3, and 4 h post-dose for a total of 8 drops (approximately 2.8 mg) each per animal. OSH grading was semi-quantitative and assessed according to a 5-point scoring scale used for clinical evaluations: 0=none; 0.5=trace; 1=mild; 2=moderate; and 3=severe. The statistical comparisons for OSH in the dog eyes consisted of testing for significance of mean differences from baseline at each time point using the Wilcoxon signed-rank test for paired observations. Differences were considered statistically significant for P-values≦0.05.

L-NAME and D-NAME did not produce conjunctival hyperemia or any adverse ocular effects at baseline (time 0). Our studies using direct evaluation of L-NAME on conjunctival hyperemia in dogs indicated the involvement of NO in OSH elicited by bimatoprost and latanoprost (Chen J et al., Invest Ophthalmol Vis Sci 2004; 45:ARVO E-Abstract 2609; FIG. 6A, 6B). The hyperemia effects elicited by bimatoprost 0.1% and latanoprost 0.005% were blocked in eyes treated with L-NAME, as shown by responses that were not different from the respective paired baseline values at 0-6 h of the study. In D-NAME treated control dog eyes, bimatoprost and latanoprost elicited trace to mild ocular surface hyperemic responses that were significantly different compared to baseline (P≦0.05). The inhibition by L-NAME in dog eyes and the in vitro rabbit jugular vein model for OSH suggests that NO is the predominant mediator of OSH for bimatoprost. L-NAME treatment also inhibited latanoprost-induced conjunctival hyperemia in dog eyes but, in this case, the D-NAME treated eyes were unaffected. This finding may possibly reflect a partial role for NO in latanoprost-induced OSH, since the vasorelaxant effects in rabbit submental veins were shown to be mediated by NO, calcitonin gene-related peptide, substance P or another tachykinin released from perivascular sensory nerves (Astin M, Stjernschantz J., Eur J Pharmacol 1997; 340:195-201; Stewart W C et al., Am J Ophthalmol 2003; 135:314-320).

In these studies, PGE₂ 0.01% served as a comparator. It produced OSH of mild to moderate severity; its effects were significantly different from those at the baseline (P≦0.05) in both the D-NAME- and L-NAME-treated eyes (Chen J et al., Invest Ophthalmol Vis Sci 2004; 45:ARVO E-Abstract 2609; FIG. 6C). The finding that L-NAME had no effect on the observed conjunctival hyperemia was predicted, since PGE₂ does not require an intact vascular endothelium to exert its relaxant response (Chen J. et al., Br J Pharmacol 1995; 116:3035-3041). These results showed that the nitric oxide synthase inhibitor L-NAME inhibits the in vivo acute OSH response to bimatoprost or latanoprost, but has no effect on PGE₂-induced OSH.

In-Life Observation and Histopathological Assessment

The ocular surface safety following bimatoprost treatment was addressed using rabbits, dogs, and non-human primates in studies of one month to one year duration. Results of the studies were submitted to worldwide regulatory authorities for the approval of bimatoprost as an antiglaucoma drug (Lumigan (Bimatoprost) Ophthalmic Solution. Pharmacology Review of New Drug Application 21-275. FDA/Center for Drug Evaluation and Research. 2001; Part 1 and Part 2:1-107. Available online at http://www fda.gov/cder/foi/nda/2001/21275 Lumigan.htm). The possible involvement of ocular surface inflammation in animal eyes treated with subclinical, clinical, and exaggerated doses of bimatoprost and controls were evaluated by in-life observations and histopathological assessment. The in-life ocular evaluations consisted of clinical observations, gross ocular observations, ophthalmoscopy, and slit lamp biomicroscopy. Histopathological assessments were conducted by three board-certified veterinary pathologists, each applying somewhat different criteria and terminology, in separate studies. The animals comprised of those scheduled for terminal sacrifice and similar numbers of males and females were used in each group. As part of a comprehensive assessment of the eye, tissues from the upper and lower eyelids with associated palpebral conjunctiva were excised for histopathological evaluation. Ocular tissues were preserved in 10% formalin, processed to paraffin, sectioned at 5 microns, and stained using H&E. The tissues were sectioned in an anatomically consistent manner for all animals in all groups. One section was evaluated for each designated site.

Rabbit Studies

The rabbit is the species most frequently used in eye irritation tests. New Zealand White (albino) rabbits were assigned to 4 groups (n=16 per group) for a one month study (Table 13). The animals received four times daily (q.i.d.) topical applications of vehicle or bimatoprost (0.001%, 0.01%, 0.1%) in the left eye, while the right eye was untreated.

TABLE 13 Incidence of minimal-to-mild mononuclear cell infiltration in palpebral conjunctiva of albino rabbits (n = 16 in each group) after daily application of bimatoprost, q.i.d. for one month Groups 1 2 3 4 Eyes Right Left Right Left Right Left Right Left Untreated Bimatoprost Untreated Bimatoprost Untreated Bimatoprost Untreated Treatment Vehicle Control 0.001% control 0.01% Control 0.1% control Upper 1 3 4 3 6 4 8 6 Eyelid Lower 15 12 12 10 13 15 14 14 Eyelid Incidence: number of animals with histopathologic findings q.i.d. = four times daily; Study 2968-58. Adapted from ref. 31.

Dutch-Belted (pigmented) rabbits were assigned to 2 groups (n=19-20 per group) and received twice daily (b.i.d.) topical ocular applications of vehicle or bimatoprost 0.03% in the left eye for one month (Table 14). The right eye was untreated. The vehicle and drug solutions were preserved with 0.005% benzalkonium chloride (BAK).

TABLE 14 Incidence of mononuclear cell infiltration in palpebral conjunctiva of pigmented rabbits after daily application of bimatoprost, b.i.d. for one month Groups 1 (n = 20) 2 (n = 19) Eyes Right Right Left Untreated Left Untreated Treatment Vehicle Control Bimatoprost 0.03% Control Upper Eyelid Minimal/mild 10 10 6 14 Lower Eyelid Minimal/mild 16 15 12 13 Moderate 1 0 0 0 Incidence: number of animals with histopathologic findings; n = number of animals per group. b.i.d. = twice daily; Study TX97032. Adapted from ref. 31.

In a six month study, Dutch-Belted (pigmented) rabbits were assigned to 4 groups (n=20 per group) (Table 15). The left eye received b.i.d. topical ocular applications of vehicle, once daily (q.d.) or b.i.d. bimatoprost 0.03%, or b.i.d. bimatoprost 0.1%. The right eye was untreated. The vehicle and drug solutions were preserved with 0.005% BAK.

TABLE 15 Mononuclear cell infiltration in palpebral conjunctiva of pigmented rabbits (n = 20 per group) after daily application of bimatoprost, q.d. or b.i.d. for 6 months Groups 1 2 3 4 Eyes Left Right Left Right Left Right Left Right Vehicle Untreated Bimatoprost Untreated Bimatoprost Untreated Bimatoprost Untreated Treatment b.i.d. Control 0.03% q.d. control 0.03.% b.i.d. Control 0.1% b.i.d. Control Upper N N N N N N N N Eyelid Lower N N N N N N N N Eyelid N = Tissues within normal histological limits q.d. = once daily; b.i.d. - twice daily; Study TX98004. Adapted from ref. 31.

Dog Study

Beagle dogs are recognized as appropriate for use in multiple-dose ocular irritation and safety studies. In a one month study, Beagle dogs were assigned to 4 groups (n=6 per group) (Table 16). The left eye was treated with q.i.d. topical ocular applications of vehicle or bimatoprost at 0.001%, 0.01%, or 0.1% doses and the right eye was untreated. All test solutions were non-preserved.

TABLE 16 Incidence of minimal-to-mild mononuclear cell infiltration in palpebral conjunctiva of dogs (n = 6 per group) after daily application of bimatoprost, q.i.d. for one month. Groups 1 2 3 4 Eyes Right Left Right Left Right Left Right Left Untreated Bimatoprost Untreated Bimatoprost Untreated Bimatoprost Untreated Treatment Vehicle Control 0.001% Control 0.01% Control 0.1% Control Upper 5 5 4 4 3 5 5 3 Eyelid Lower 5 5 3 4 5 5 6 6 Eyelid Incidence: number of animals with histopathologic findings q.i.d. = four times daily; Study 3137-5. Adapted from ref. 31.

Non-Human Primate Study

Cynomolgus monkeys have been historically used in safety evaluation studies and are recommended by most regulatory agencies. In a 12 month study, Cynomolgus monkeys scheduled for terminal sacrifice were assigned to 4 groups (n=6-8 per group) (Table 17). The right eyes were treated with topical ocular applications of vehicle b.i.d., bimatoprost 0.03% q.d., bimatoprost 0.03% b.i.d., or bimatoprost 0.1% b.i.d. The left eye was not treated. All test solutions were preserved with 0.005% BAK.

TABLE 17 Incidence of inflammation in palpebral conjunctiva of cynomolgus monkeys after daily application of bimatoprost, q.d. or b.i.d. for 12 months. Groups 1 (n = 6) 2 (n = 8) 3 (n = 6) 4 (n-6) Eyes Left Right Left Right Left Right Left Right Untreated Vehicle Untreated Bimatoprost Untreated Bimatoprost Untreated Bimatoprost Treatment control b.i.d. control 0.03% q.d. control 0.03% b.i.d. control 0.1% b.i.d. Upper Eyelid Chronic active 5 5 4 4 3 5 5 3 Lower Eyelid Subacute Chronic active Incidence: number of animals with histopathologic findings; n = number of animals per group. q.d. = once daily; b.i.d. = twice daily; Study 6177-110. Adapted from ref. 31.

Summary of In-Life Observations and Histopathological Assessments

No compound-related findings of corneal toxicity, discomfort or irritation, or histopathological changes were observed in eyes of the animal species treated with multiple subclinical, clinical, and exaggerated doses of bimatoprost. Histopathological evaluations of eyes treated with the highest dose and frequency of application of bimatoprost in each study were compared to vehicle treatment. The results are summarized in Table 18. Only vehicle-treated eyes showed inflammatory changes above background stimulation in the palpebral conjunctiva, whereas no such changes were related to bimatoprost treatment. The presence of minimal to mild inflammatory infiltrates (background stimulation) in conjunctiva of untreated control eyes, vehicle-treated eyes, and bimatoprost-treated eyes was considered to be incidental and unrelated to treatment. In all the studies, bimatoprost did not increase the intensity or alter the characteristics of inflammatory processes in the conjunctiva.

TABLE 18 Summary of incidence of histopathologic findings above background stimulation in the lower palpebral conjunctiva after topical administration of bimatoprost Incidence of Highest dose & inflammatory Duration frequency infiltrates above Species Strain months tested background Rabbits New Zealand 1 0.1% q.i.d. 0 (16) White Vehicle 0 (16) Rabbits Dutch-Belted 1 0.03% b.i.d. 0 (19) Vehicle 1 (20) Rabbits Dutch-Belted 6 0.1% b.i.d. 1 (20) Vehicle 0 (20) Dogs Beagle 1 0.1% q.i.d. 0 (6) Vehicle 0 (6) Monkeys Cynomolgus 12 0.1% b.i.d. 0 (60) Vehicle 1 (6) Incidence: number of animals with histopathologic findings (per total number of animals) Adapted from ref. 31.

The in-life evaluations indicated no treatment-related ocular surface inflammation in animals treated with bimatoprost for periods of up to one year exposure. Minimal to mild mononuclear infiltrates were recognizable in routine sampling of the conjunctiva of untreated and treated laboratory animals. Such changes represent background stimulation of this mucosal barrier. Thus, across all studies and species, the results indicated that bimatoprost does not increase the intensity or alter the characteristics of inflammatory processes in the conjunctiva of animals. These findings are more in agreement with a protective role for eNOS rather than involvement in pro-inflammatory processes. The safety evaluation results for animals treated with bimatoprost correlate with the clinical assessments suggesting that bimatoprost-related conjunctival hyperemia occurs by a non-inflammatory mechanism (Abelson M B et al., Adv Ther 2003; 20:1-13; Guenoun J-M et al., Invest Ophthalmol Vis Sci 2005; 46:2444-2450; Higginbotham E J, Schuman J S, Goldberg I, et al., Arch Ophthalmol 2002; 120:1286-1293; Leal B C et al., Am J Ophthalmol 2004; 138:310-313; Lumigan (Bimatoprost) Ophthalmic Solution. Pharmacology Review of New Drug Application 21-275. FDA/Center for Drug Evaluation and Research. 2001; Part 1 and Part 2:1-107. Available online at http://www.fda.gov/cder/foi/nda/2001/21275_Lumigan.htm; Mroz M, Abelson M B et al., Invest Ophthalmol Vis Sci 2003; 44:ARVOE-Abstract 4417; Noecker R S et al., Am J Ophthalmol 2003; 135:55-63).

CONCLUSIONS

The results of pharmacological studies of OSH indicate that bimatoprost and latanoprost elicit conjunctival hyperemia by a common signaling mechanism that involves intracellular calcium and endothelial-derived nitric oxide. Extensive safety evaluation studies of bimatoprost at clinical and exaggerated doses in three species of laboratory animals found no evidence of treatment-related ocular surface inflammation. The results showed that bimatoprost has a very high safety margin and is well-tolerated in animals.

Clinical Studies with Bimatoprost in Combination with Timolol

Approximately 60% of patients being treated for glaucoma require two or more agents (adjuvant therapy) to control the intraocular pressure. For this reason, combination therapies, in which two pharmaceutically active agents are combined in the same formulation, have been developed to decrease complexity in the treatment regimen, improve patient compliance, and to minimize the exposure to excipients with possible toxicity such as benzalkonium chloride. Currently, the most commonly prescribed adjuvant therapy includes a beta-blocker and a prostaglandin analogue. For this reason, Allergan has formulated bimatoprost 0.03% together with timolol 0.5% (Combination). To date, four pivotal clinical trials have been conducted that compares the combination with monotherapy (bimatoprost 0.03% once a day given individually) Unexpectedly, there were substantial reductions in the degree of ocular surface hyperemia observed with the combination compared with monotherapy as reported as adverse events or treatment-related adverse events in the pooled data from the 018T and 021T studies as well as from the 026T study (table) suggesting that the timolol may have been responsible for the decrease in hyperemia.

TABLE 19 Phase 3 Studies: Incidence of Conjunctival hyperaemia Detected on Biomicroscopy and Reported as a Treatment-Related AE for Patients in the Combination Group Combination Bimatoprost Biomicro Rx-rel Biomicro Rx-rel ≧+1 AE ≧+1 AE Pooled 192024-018T & 021T 15.6%^(a) 22.7%^(a) 30.9% 38.5% (3 months) Pooled 192024-018T & 021T 22.1%^(a) 25.7%^(a) 41.5% 43.4% (3 months) 192024-504T (3 months) 20.4% 25.0% 21.1% 29.9% 192024-026T (3 weeks) 8.5% 19.3% 18.9% 27.8% * Combination statistically significantly lower than Bimatoprost (p ≦ 0.024)

The mechanism of the effect is not certain; however, it is well-known that beta blockade can induce an unopposed alpha agonism leading to vasoconstriction and decrease ocular hyperemia. (see first two reference at the end) More recently, it has been shown that nitric oxide synthase is under beta-adrenergic control. This suggests that beta-blockade should decrease the production of nitric oxide resulting from the topical exposure of the prostaglandin analogue to the ocular surface reducing the severity of ocular surface hyperemia (the remainder of references at the end of the document). 

What is claimed is:
 1. A composition comprising a prostaglandin agent and a vasoconstrictor agent.
 2. The composition of claim 1, wherein said composition is an ophthalmic pharmaceutical formulation further comprising an ophthalmically acceptable excipient.
 3. The composition of claim 1, wherein said prostaglandin agent is present in a therapeutically effective amount.
 4. The composition of claim 1, wherein said vasoconstrictor agent is present in a sub-therapeutic amount.
 5. The composition of claim 2, wherein said prostaglandin agent and said vasoconstrictor agent are present in a combined amount effective to treat an ophthalmic disease.
 6. The composition of claim 2, wherein said ophthalmic pharmaceutical formulation is a gel formulation.
 7. The composition of claim 2, wherein said ophthalmic pharmaceutical formulation is an aqueous solution.
 8. The composition of claim 2, wherein said prostaglandin agent is bimatoprost.
 9. The composition of claim 8, wherein said bimatoprost is present in an amount approximately equal to or less than about 0.1% w/w.
 10. The composition of claim 8, wherein said bimatoprost is present in an amount of about 0.03% w/w.
 11. The composition of claim 2, wherein said prostaglandin agent is travoprost.
 12. The composition of claim 11, wherein said travoprost is present in an amount approximately equal to or less than about 0.1% w/w.
 13. The composition of claim 11, wherein said travoprost is present in an amount of about 0.004% w/w.
 14. The composition of claim 2, wherein said prostaglandin agent is latanoprost.
 15. The composition of claim 14, wherein said latanoprost is present in an amount approximately equal to or less than about 0.1% w/w.
 16. The composition of claim 14, wherein said latanoprost is present in an amount of about 0.005% w/w.
 17. The composition of claim 2, wherein said vasoconstrictor agent is an alpha adrenergic agonist.
 18. The composition of claim 2, wherein said vasoconstrictor agent is selected from the group consisting of befunolol, betaxolol, carteolol, levobunolol, metipranolol, timolol, brimonidine, tetrahydrozolone hydrochloride and mepindolol.
 19. The composition of claim 18, wherein the vasoconstrictor agent is timolol.
 20. The composition of claim 19, wherein said timolol is present in a sub-therapeutic amount. 